Healthcare Provider Details

I. General information

NPI: 1457047565
Provider Name (Legal Business Name): NIDIA GAMEZ NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 11/14/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 JENSEN ST ENUMCLAW, WA 98022
ENUMCLAW WA
98022
US

IV. Provider business mailing address

3100 SE 168TH AVE APT 28
VANCOUVER WA
98683-2104
US

V. Phone/Fax

Practice location:
  • Phone: 360-825-2541
  • Fax:
Mailing address:
  • Phone: 909-510-2871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number62868
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2022114165
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number695054
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number61064484
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number62868
License Number StateID
# 6
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number61064484
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: