Provider Demographics
NPI:1265020622
Name:GONZALEZ, ELISABETH RENAE
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:RENAE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 AMBERGATE PL APT A109
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-2647
Mailing Address - Country:US
Mailing Address - Phone:951-255-7263
Mailing Address - Fax:
Practice Address - Street 1:7600 AMBERGATE PL APT A109
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-2647
Practice Address - Country:US
Practice Address - Phone:951-255-7263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-01
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95120051163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care