Provider Demographics
NPI:1902667900
Name:GONZALEZ, AMANDA NICOLE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
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 1:4560 MISSION GORGE PL APT 565
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-4191
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2240 E PLAZA BLVD STE B-E
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-5164
Practice Address - Country:US
Practice Address - Phone:619-474-5916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25893225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist