Healthcare Provider Details

I. General information

NPI: 1114301967
Provider Name (Legal Business Name): PEGGY GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15251 N 45TH PL
PHOENIX AZ
85032-4840
US

IV. Provider business mailing address

PO BOX 12007
SCOTTSDALE AZ
85267-2007
US

V. Phone/Fax

Practice location:
  • Phone: 602-818-7447
  • Fax:
Mailing address:
  • Phone: 602-818-7447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: