Healthcare Provider Details

I. General information

NPI: 1467363416
Provider Name (Legal Business Name): KETSIALYS GONZALEZ-LATORRE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 HOLMES AVE
CLARENDON HILLS IL
60514-1698
US

IV. Provider business mailing address

17W730 BUTTERFIELD RD APT 119
OAKBROOK TERRACE IL
60181-4241
US

V. Phone/Fax

Practice location:
  • Phone: 630-325-3265
  • Fax: 630-325-8682
Mailing address:
  • Phone: 630-325-3265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051309510
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: