Provider Demographics
NPI:1336305507
Name:GONZALEZ, WILMA GLORIA
Entity Type:Individual
Prefix:
First Name:WILMA
Middle Name:GLORIA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:W
Other - Middle Name:GLORIA
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:158 CALLE RENATA
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3956
Mailing Address - Country:US
Mailing Address - Phone:909-592-1028
Mailing Address - Fax:
Practice Address - Street 1:158 CALLE RENATA
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3956
Practice Address - Country:US
Practice Address - Phone:909-592-1028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-06
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA990454133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered