Provider Demographics
NPI:1750081899
Name:GONZALEZ, MIREYA (IBCLC)
Entity type:Individual
Prefix:
First Name:MIREYA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:TECPAXOCHITL
Other - Middle Name:MIREYA
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IBCLC
Mailing Address - Street 1:14621 VAN NUYS PL
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-1024
Mailing Address - Country:US
Mailing Address - Phone:818-747-4292
Mailing Address - Fax:
Practice Address - Street 1:14621 VAN NUYS PL
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-1024
Practice Address - Country:US
Practice Address - Phone:818-747-4292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-07
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-308221174N00000X
374J00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula