Healthcare Provider Details

I. General information

NPI: 1861751026
Provider Name (Legal Business Name): IRENE GOMEZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14540 OLD SAINT AUGUSTINE RD STE 2403
JACKSONVILLE FL
32258-7418
US

IV. Provider business mailing address

1443 SAN MARCO BLVD STE 101
JACKSONVILLE FL
32207-8535
US

V. Phone/Fax

Practice location:
  • Phone: 904-253-6910
  • Fax: 904-253-6964
Mailing address:
  • Phone: 904-253-6910
  • Fax: 904-253-6964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN11028156
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number303828-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: