Provider Demographics
NPI:1649798984
Name:GONZALES, LARRISA BREANNE
Entity type:Individual
Prefix:
First Name:LARRISA
Middle Name:BREANNE
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 1:11601 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-5006
Mailing Address - Country:US
Mailing Address - Phone:323-242-5000
Mailing Address - Fax:
Practice Address - Street 1:15116 S GIBSON AVE
Practice Address - Street 2:
Practice Address - City:EAST RANCHO DOMINGUEZ
Practice Address - State:CA
Practice Address - Zip Code:90221-3106
Practice Address - Country:US
Practice Address - Phone:323-242-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program