Provider Demographics
NPI:1356604193
Name:VILLAGOMEZ, CORA
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:
Last Name:VILLAGOMEZ
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 1:8871 KIMBALL ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68122-5211
Mailing Address - Country:US
Mailing Address - Phone:402-707-3605
Mailing Address - Fax:
Practice Address - Street 1:7101 NEWPORT AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68152-2164
Practice Address - Country:US
Practice Address - Phone:402-572-2333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE111359363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily