Provider Demographics
NPI:1902098726
Name:GONZALES, MICHELLE ANNE (LVN, RAS)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANNE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LVN, RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 N DATE ST
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3405
Mailing Address - Country:US
Mailing Address - Phone:760-745-7786
Mailing Address - Fax:760-745-1061
Practice Address - Street 1:910 E OHIO AVE STE 104
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025
Practice Address - Country:US
Practice Address - Phone:760-745-7786
Practice Address - Fax:760-745-1061
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GO402241157101YA0400X
CAVN181643164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)