Provider Demographics
NPI:1922316769
Name:GONZALES, RENEE D
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:D
Last Name:GONZALES
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 1:15536 L ST
Mailing Address - Street 2:
Mailing Address - City:MOJAVE
Mailing Address - State:CA
Mailing Address - Zip Code:93501-1828
Mailing Address - Country:US
Mailing Address - Phone:661-824-3536
Mailing Address - Fax:
Practice Address - Street 1:15536 L ST
Practice Address - Street 2:
Practice Address - City:MOJAVE
Practice Address - State:CA
Practice Address - Zip Code:93501-1828
Practice Address - Country:US
Practice Address - Phone:661-824-3536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2633765OtherPENNY LANE