=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780666743
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNETTE GOMEZ RNC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2005
-----------------------------------------------------
Last Update Date | 10/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17323 IH 35 N STE 113
-----------------------------------------------------
City | SCHERTZ
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78154-1278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-656-4878
-----------------------------------------------------
Fax | 210-745-0562
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 196 FOX RDG
-----------------------------------------------------
City | CANYON LAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78133-5408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-464-7753
-----------------------------------------------------
Fax | 210-745-0562
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 565954
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------