Healthcare Provider Details

I. General information

NPI: 1881857167
Provider Name (Legal Business Name): HOLLY LYNN GOMEZ-LEVINE APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 TOWER AVE
SUPERIOR WI
54880-4491
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 715-817-7100
  • Fax: 406-457-8992
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number100926
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number7182-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: