Healthcare Provider Details

I. General information

NPI: 1538539762
Provider Name (Legal Business Name): KATELYN GOMEZ R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6613 W FAIRVIEW AVE
MILWAUKEE WI
53213-3934
US

IV. Provider business mailing address

6613 W FAIRVIEW AVE
MILWAUKEE WI
53213-3934
US

V. Phone/Fax

Practice location:
  • Phone: 651-491-9745
  • Fax:
Mailing address:
  • Phone: 651-491-9745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number168813
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: