Provider Demographics
NPI:1245920248
Name:GONZALEZ MACCALL, JULISSA
Entity type:Individual
Prefix:
First Name:JULISSA
Middle Name:
Last Name:GONZALEZ MACCALL
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 1:616 SIMPSON ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5321
Mailing Address - Country:US
Mailing Address - Phone:707-790-7813
Mailing Address - Fax:
Practice Address - Street 1:616 SIMPSON ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5321
Practice Address - Country:US
Practice Address - Phone:707-790-7813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist