Provider Demographics
NPI:1396345948
Name:GONZALES, MYLENE LILIAN
Entity type:Individual
Prefix:
First Name:MYLENE LILIAN
Middle Name:
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 1:5727 GROVE FARM CT NW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-6081
Mailing Address - Country:US
Mailing Address - Phone:770-403-2186
Mailing Address - Fax:
Practice Address - Street 1:5727 GROVE FARM CT NW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-6081
Practice Address - Country:US
Practice Address - Phone:770-403-2186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN249672363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty