Provider Demographics
NPI:1114355302
Name:GOMEZ, LILIET (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LILIET
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 OAK ST
Mailing Address - Street 2:APT 1
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-1980
Mailing Address - Country:US
Mailing Address - Phone:978-407-3125
Mailing Address - Fax:
Practice Address - Street 1:30 E 33RD ST FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5337
Practice Address - Country:US
Practice Address - Phone:123-554-4592
Practice Address - Fax:347-823-1561
Is Sole Proprietor?:No
Enumeration Date:2013-10-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF339633-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04750712Medicaid
NY1114355302OtherNPI
NYMG4693190OtherDEA