Healthcare Provider Details

I. General information

NPI: 1972171015
Provider Name (Legal Business Name): JENNIFER GOMEZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 BAINBRIDGE AVE FL 5
BRONX NY
10467-2403
US

IV. Provider business mailing address

1610 WALTON AVE APT 4I
BRONX NY
10452-5935
US

V. Phone/Fax

Practice location:
  • Phone: 718-741-2507
  • Fax: 718-405-5260
Mailing address:
  • Phone: 646-982-6114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number383233
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: