Provider Demographics
NPI:1225759806
Name:GOMEZ, KATELYN G
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:G
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23635 SORESINA
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-1832
Mailing Address - Country:US
Mailing Address - Phone:949-735-4670
Mailing Address - Fax:
Practice Address - Street 1:50 ACACIA AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2230
Practice Address - Country:US
Practice Address - Phone:415-457-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program