Healthcare Provider Details

I. General information

NPI: 1972277622
Provider Name (Legal Business Name): LOREN EBRADA GOMES APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 MASON AVE
DAYTONA BEACH FL
32117-4551
US

IV. Provider business mailing address

1690 DUNLAWTON AVE
PORT ORANGE FL
32127-8979
US

V. Phone/Fax

Practice location:
  • Phone: 386-274-2000
  • Fax: 386-274-2009
Mailing address:
  • Phone: 386-271-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberF12200547
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number11011081
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: