Healthcare Provider Details

I. General information

NPI: 1508281908
Provider Name (Legal Business Name): GRIVEL JUSTINA HERA GOMEZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2014
Last Update Date: 02/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 S MIAMI AVE
MIAMI FL
33130-4100
US

IV. Provider business mailing address

610 W 53RD ST
HIALEAH FL
33012-2576
US

V. Phone/Fax

Practice location:
  • Phone: 305-571-6250
  • Fax:
Mailing address:
  • Phone: 305-793-8839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily
License NumberARNP9302035
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: