Healthcare Provider Details

I. General information

NPI: 1164995759
Provider Name (Legal Business Name): ANN ELISABETH GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANN ELISABETH GUILLAUME

II. Dates (important events)

Enumeration Date: 01/07/2019
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

19432 SW 68TH ST
FORT LAUDERDALE FL
33332-1649
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11000781
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: