Healthcare Provider Details

I. General information

NPI: 1447181706
Provider Name (Legal Business Name): JORGE LUIS GOMEZ VELEZ
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 343
WIMAUMA FL
33598-0343
US

IV. Provider business mailing address

PO BOX 343
WIMAUMA FL
33598-0343
US

V. Phone/Fax

Practice location:
  • Phone: 813-406-0303
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11047747
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: