Provider Demographics
NPI:1659790756
Name:GOMEZ-LEFFALL, MICHELE S (GRN)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:S
Last Name:GOMEZ-LEFFALL
Suffix:
Gender:F
Credentials:GRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 W WHEATLAND RD STE 180
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-4600
Mailing Address - Country:US
Mailing Address - Phone:469-254-5346
Mailing Address - Fax:682-759-5955
Practice Address - Street 1:402 W WHEATLAND RD STE 180
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4600
Practice Address - Country:US
Practice Address - Phone:469-254-5346
Practice Address - Fax:682-759-5955
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747A0650X, 174H00000X, 261Q00000X, 261QP0905X
TX308029164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or LocalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1992393268Medicaid