Provider Demographics
NPI:1740783984
Name:GOMEZ, RAVEN S (LVN)
Entity type:Individual
Prefix:MRS
First Name:RAVEN
Middle Name:S
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 1:775 OLD JEFFERSON RD
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TX
Mailing Address - Zip Code:75460-7847
Mailing Address - Country:US
Mailing Address - Phone:903-272-7408
Mailing Address - Fax:
Practice Address - Street 1:3605 NE LOOP 286 STE 200
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TX
Practice Address - Zip Code:75460-5091
Practice Address - Country:US
Practice Address - Phone:903-737-4337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX315042164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX315042OtherLICENSED VOCATIONAL NURSE