Healthcare Provider Details

I. General information

NPI: 1316865926
Provider Name (Legal Business Name): FATIMA VALDIVIA GOMEZ PPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2617 E LINCOLNWAY STE G
CHEYENNE WY
82001-5671
US

IV. Provider business mailing address

2617 E LINCOLNWAY STE G
CHEYENNE WY
82001-5671
US

V. Phone/Fax

Practice location:
  • Phone: 307-514-1288
  • Fax:
Mailing address:
  • Phone: 307-514-1288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPPC1689
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: