Healthcare Provider Details

I. General information

NPI: 1184406522
Provider Name (Legal Business Name): CRYSTALOREN M. GOMEZ FNP-BC, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2023
Last Update Date: 04/12/2026
Certification Date: 04/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13223 BLACK MOUNTAIN RD STE 1 PMB 1014
SAN DIEGO CA
92129-2699
US

IV. Provider business mailing address

13223 BLACK MOUNTAIN RD STE 1 STE 1 PMB 1014
SAN DIEGO CA
92129-2699
US

V. Phone/Fax

Practice location:
  • Phone: 619-853-5578
  • Fax:
Mailing address:
  • Phone: 619-853-5578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95027133
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number336868
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number88797
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: