Provider Demographics
NPI:1417179110
Name:GOMBERT, SHERYL RAE (CNM)
Entity Type:Individual
Prefix:
First Name:SHERYL
Middle Name:RAE
Last Name:GOMBERT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 N RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3722
Mailing Address - Country:US
Mailing Address - Phone:208-529-4635
Mailing Address - Fax:
Practice Address - Street 1:1600 S 25TH E
Practice Address - Street 2:EASTERN IDAHO TECHNICAL COLLEGE
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-5788
Practice Address - Country:US
Practice Address - Phone:208-524-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNM 22-C176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife