Provider Demographics
NPI:1497103113
Name:GONZALEZ, KETTY
Entity Type:Individual
Prefix:
First Name:KETTY
Middle Name:
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 1:771 SE 2ND PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-5405
Mailing Address - Country:US
Mailing Address - Phone:305-801-5996
Mailing Address - Fax:
Practice Address - Street 1:12855 SW 132ND ST
Practice Address - Street 2:SUITE 207
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-7207
Practice Address - Country:US
Practice Address - Phone:786-587-0424
Practice Address - Fax:786-250-5094
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other