Provider Demographics
NPI:1750660890
Name:GOMEZ, LISA M (LPN-M-IV)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:LPN-M-IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2980 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1834
Mailing Address - Country:US
Mailing Address - Phone:330-759-2310
Mailing Address - Fax:330-759-0018
Practice Address - Street 1:2980 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-1834
Practice Address - Country:US
Practice Address - Phone:330-759-2310
Practice Address - Fax:330-759-0018
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-088162-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse