Provider Demographics
NPI:1639713043
Name:GOMEZ, DIANA (MSN, FNP, APRN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:MSN, FNP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 SW 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-5185
Mailing Address - Country:US
Mailing Address - Phone:786-219-6924
Mailing Address - Fax:
Practice Address - Street 1:3407 SW 15TH AVE
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-5185
Practice Address - Country:US
Practice Address - Phone:786-219-6924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004773363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty