Healthcare Provider Details

I. General information

NPI: 1154169993
Provider Name (Legal Business Name): AMBER C GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 SKYLAND DR
BELLBROOK OH
45305-8717
US

IV. Provider business mailing address

332 SKYLAND DR
BELLBROOK OH
45305-8717
US

V. Phone/Fax

Practice location:
  • Phone: 478-396-9283
  • Fax:
Mailing address:
  • Phone: 478-396-9283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0037128
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN277606
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: