MEDICARE: GOMA MAYBERRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN9308893	FL

General Provider Information

NPI Number	:	1588101174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GOMA MAYBERRY

Provider Business Mailing Address
First Line	:	773 RIVERSIDE DR
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32176-7878
Country	:	US
Telephone Number	:	386-795-2457
Fax Number	:

Provider Business Practice Location Address
First Line	:	773 RIVERSIDE DR
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32176-7878
Country	:	US
Telephone Number	:	386-795-2457
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2017
Last Update Date	:	01/20/2017

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Directions to “ GOMA MAYBERRY ” Practice Location

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