Healthcare Provider Details

I. General information

NPI: 1669664165
Provider Name (Legal Business Name): MISS NICOLE MARIE GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 WILLIAMS DR
SOUTH ELGIN IL
60177-2538
US

IV. Provider business mailing address

620 WILLIAMS DR
SOUTH ELGIN IL
60177-2538
US

V. Phone/Fax

Practice location:
  • Phone: 630-456-2423
  • Fax:
Mailing address:
  • Phone: 630-456-2423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number056.007929
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: