Provider Demographics
NPI:1821709304
Name:GOMEZ MEJIA, MARIELY C
Entity Type:Individual
Prefix:
First Name:MARIELY
Middle Name:C
Last Name:GOMEZ MEJIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIELY
Other - Middle Name:C
Other - Last Name:GOMEZ MEJIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1912 S MARYLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-3106
Mailing Address - Country:US
Mailing Address - Phone:702-331-3650
Mailing Address - Fax:
Practice Address - Street 1:1912 S MARYLAND PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-3106
Practice Address - Country:US
Practice Address - Phone:702-331-3650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2102241300OtherNV DRIVER LICENSE CARD