Healthcare Provider Details

I. General information

NPI: 1447723796
Provider Name (Legal Business Name): BLAKE KATHLEEN GOMEZ CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BLAKE KATHLEEN WINCENTSEN

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

IV. Provider business mailing address

10860 KINGSBOROUGH TRL
COTTAGE GROVE MN
55016-4660
US

V. Phone/Fax

Practice location:
  • Phone: 612-813-7888
  • Fax: 612-813-6361
Mailing address:
  • Phone: 651-769-5002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number209018598
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number8198
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: