Healthcare Provider Details

I. General information

NPI: 1992369508
Provider Name (Legal Business Name): GRISMELDY E GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 06/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 VILLAGE CIRCLE DR
WINFIELD MO
63389-2053
US

IV. Provider business mailing address

61 VILLAGE CIRCLE DR
WINFIELD MO
63389-2053
US

V. Phone/Fax

Practice location:
  • Phone: 636-322-8517
  • Fax:
Mailing address:
  • Phone: 636-322-8517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2013026395
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number53-78743-011
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: