Healthcare Provider Details

I. General information

NPI: 1770551632
Provider Name (Legal Business Name): JACQUELINE A GOMOGDA RNC, WHNP,ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12271 US HIGHWAY 301 N
PARRISH FL
34219-8410
US

IV. Provider business mailing address

700 8TH AVE W STE 101
PALMETTO FL
34221-4737
US

V. Phone/Fax

Practice location:
  • Phone: 941-776-4050
  • Fax: 941-776-4057
Mailing address:
  • Phone: 941-776-4008
  • Fax: 941-845-4963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number2698092
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: