Provider Demographics
NPI:1073166195
Name:GONZALEZ, MAYELYN (SA-C)
Entity Type:Individual
Prefix:
First Name:MAYELYN
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1352 W 42ND ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5940
Mailing Address - Country:US
Mailing Address - Phone:305-984-0180
Mailing Address - Fax:
Practice Address - Street 1:1352 W 42ND ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5940
Practice Address - Country:US
Practice Address - Phone:305-984-0180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19-301246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant