Provider Demographics
NPI:1275257644
Name:VIDAL GOMEZ, CRISTEVY M (IBCLC)
Entity Type:Individual
Prefix:
First Name:CRISTEVY
Middle Name:M
Last Name:VIDAL GOMEZ
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4324 NW 115TH CT
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4229
Mailing Address - Country:US
Mailing Address - Phone:978-905-9124
Mailing Address - Fax:
Practice Address - Street 1:4324 NW 115TH CT
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-4229
Practice Address - Country:US
Practice Address - Phone:978-905-9124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Single Specialty