Provider Demographics
NPI:1154006310
Name:GONZALES, MAYETTE BAYLON (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MAYETTE
Middle Name:BAYLON
Last Name:GONZALES
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4783 BRISON CT
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91752-5070
Mailing Address - Country:US
Mailing Address - Phone:818-297-4399
Mailing Address - Fax:
Practice Address - Street 1:3988 MERRILL AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2214
Practice Address - Country:US
Practice Address - Phone:909-304-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF03230094207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine