Provider Demographics
NPI:1992369508
Name:GOMEZ, GRISMELDY E
Entity Type:Individual
Prefix:
First Name:GRISMELDY
Middle Name:E
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 VILLAGE CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63389-2053
Mailing Address - Country:US
Mailing Address - Phone:636-322-8517
Mailing Address - Fax:
Practice Address - Street 1:61 VILLAGE CIRCLE DR
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:MO
Practice Address - Zip Code:63389-2053
Practice Address - Country:US
Practice Address - Phone:636-322-8517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013026395163W00000X
KS53-78743-011363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse