Provider Demographics
NPI:1568237220
Name:GONZALEZ, SAMRAH MARISOL
Entity Type:Individual
Prefix:
First Name:SAMRAH
Middle Name:MARISOL
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 1:161 LAURIE MEADOWS DR APT 568
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-4839
Mailing Address - Country:US
Mailing Address - Phone:415-596-1332
Mailing Address - Fax:
Practice Address - Street 1:3037 BRYANT PL
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-1613
Practice Address - Country:US
Practice Address - Phone:415-596-1332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA692429164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse