MEDICARE: MS. NAYRA LISETH GOMEZ-PENA OCCUPATIONAL THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	0T19153	FL

General Provider Information

NPI Number	:	1407195886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NAYRA LISETH GOMEZ-PENA OCCUPATIONAL THERAPY

Provider Business Mailing Address
First Line	:	287 MEEHAN AVE NW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-2970
Country	:	US
Telephone Number	:	321-507-8267
Fax Number	:

Provider Business Practice Location Address
First Line	:	287 MEEHAN AVE NW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32907-2970
Country	:	US
Telephone Number	:	321-507-8267
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2013
Last Update Date	:	10/11/2019

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