Provider Demographics
NPI:1780468546
Name:GOMEZ, NICHOLAS ALEXANDER (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:ALEXANDER
Last Name:GOMEZ
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:2050 N MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307
Practice Address - Country:US
Practice Address - Phone:219-662-3300
Practice Address - Fax:219-662-3301
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71015668A363LP0808X
IN28261371A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health