Provider Demographics
NPI:1770041832
Name:GOMEZ, ENRIQUETA R (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:ENRIQUETA
Middle Name:R
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7438 W JONQUIL TER
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-3104
Mailing Address - Country:US
Mailing Address - Phone:847-414-3869
Mailing Address - Fax:
Practice Address - Street 1:900 TECHNOLOGY WAY STE 280
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5364
Practice Address - Country:US
Practice Address - Phone:847-549-0588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017095363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology