Provider Demographics
NPI:1124724695
Name:GONZALEZ, KAYLIN SHAE
Entity type:Individual
Prefix:
First Name:KAYLIN
Middle Name:SHAE
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 1:827 LEVERING AVE APT 402
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-2737
Mailing Address - Country:US
Mailing Address - Phone:951-514-0049
Mailing Address - Fax:
Practice Address - Street 1:1411 E 31ST ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-1018
Practice Address - Country:US
Practice Address - Phone:951-514-0049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program