Provider Demographics
NPI:1255198560
Name:GOMEZ, ANGELICA SERANIE (LVN)
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:SERANIE
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-1011
Mailing Address - Country:US
Mailing Address - Phone:708-856-1099
Mailing Address - Fax:
Practice Address - Street 1:1733 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-5414
Practice Address - Country:US
Practice Address - Phone:619-263-0433
Practice Address - Fax:619-263-3992
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA739990164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse