Provider Demographics
NPI:1568012763
Name:GOMEZ, GRISELDA P (LVN)
Entity Type:Individual
Prefix:
First Name:GRISELDA
Middle Name:P
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 W TEEGE AVE
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78550-4667
Mailing Address - Country:US
Mailing Address - Phone:956-412-3337
Mailing Address - Fax:
Practice Address - Street 1:2102 W TEEGE AVE
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78550-4667
Practice Address - Country:US
Practice Address - Phone:956-412-3337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332749164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1790847531Medicaid