Healthcare Provider Details

I. General information

NPI: 1073478624
Provider Name (Legal Business Name): SHEYENNE GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WHITE EAGLE DR
PONCA CITY OK
74601-8315
US

IV. Provider business mailing address

111 LANSBROOK RD
PONCA CITY OK
74601-7407
US

V. Phone/Fax

Practice location:
  • Phone: 580-762-3421
  • Fax:
Mailing address:
  • Phone: 580-485-8265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: