Provider Demographics
NPI:1396314746
Name:GONZALEZ, JULIE ELENY (BA)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:ELENY
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 SW 10TH ST APT 406
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-4578
Mailing Address - Country:US
Mailing Address - Phone:909-851-4181
Mailing Address - Fax:
Practice Address - Street 1:707 SW 10TH ST APT 406
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4578
Practice Address - Country:US
Practice Address - Phone:909-851-4181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR379246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR2008837905OtherPACIFIC SOURCE