Provider Demographics
NPI:1245377316
Name:GOMES, MARIA GRACE
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:GRACE
Last Name:GOMES
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 1:123 LONG POINTE DR
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1389
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:943 HUALAPAI WAY
Practice Address - Street 2:
Practice Address - City:PEACH SPRINGS
Practice Address - State:AZ
Practice Address - Zip Code:86434-0190
Practice Address - Country:US
Practice Address - Phone:928-769-2959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO08505700163WC0200X
TX671937163WE0003X
FLRN9224875163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Not Answered163WE0003XNursing Service ProvidersRegistered NurseEmergency
Not Answered163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZHSZ135Medicare ID - Type UnspecifiedDHHSIHS
AZHSZ137Medicare ID - Type UnspecifiedDHHSIHS