Provider Demographics
NPI:1952800351
Name:VILLAGOMEZ, LELIE
Entity type:Individual
Prefix:
First Name:LELIE
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 1:1098 MIDWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-1345
Mailing Address - Country:US
Mailing Address - Phone:510-258-7812
Mailing Address - Fax:
Practice Address - Street 1:1098 MIDWAY AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-1345
Practice Address - Country:US
Practice Address - Phone:510-258-7812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA690079164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse