Healthcare Provider Details

I. General information

NPI: 1265324719
Provider Name (Legal Business Name): CITLALLI GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2025
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 W SOUTHERN HILLS BLVD
ROGERS AR
72758-8113
US

IV. Provider business mailing address

14459 HIGHLAND CHURCH RD
FAYETTEVILLE AR
72704-0314
US

V. Phone/Fax

Practice location:
  • Phone: 479-770-0744
  • Fax:
Mailing address:
  • Phone: 479-684-1275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberTEMP234056
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: