Provider Demographics
NPI:1497246524
Name:GOMEZ, KATRENNA DALE (LPN)
Entity Type:Individual
Prefix:
First Name:KATRENNA
Middle Name:DALE
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12309 E 25TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-5820
Mailing Address - Country:US
Mailing Address - Phone:918-720-8204
Mailing Address - Fax:918-771-3803
Practice Address - Street 1:12309 E 25TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-5820
Practice Address - Country:US
Practice Address - Phone:918-720-8204
Practice Address - Fax:918-771-3803
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK57534164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse