Provider Demographics
NPI:1427538578
Name:VEGA GOMEZ, DIANA ROSA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:ROSA
Last Name:VEGA 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 1:2201 SW 67TH AVE APT 223
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1994
Mailing Address - Country:US
Mailing Address - Phone:702-241-5783
Mailing Address - Fax:
Practice Address - Street 1:2201 SW 67TH AVE APT 223
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-1994
Practice Address - Country:US
Practice Address - Phone:702-241-5783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1705055397OtherDL