Healthcare Provider Details

I. General information

NPI: 1710439641
Provider Name (Legal Business Name): MICHELLE EVELYN GOMEZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9241 E CADENCE PKWY STE 101
MESA AZ
85212-0021
US

IV. Provider business mailing address

1066 N POWER RD # SUIE101
MESA AZ
85205-5709
US

V. Phone/Fax

Practice location:
  • Phone: 480-626-7203
  • Fax:
Mailing address:
  • Phone: 480-807-0130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10811
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: