Provider Demographics
NPI:1124311196
Name:GOMES, DANIELLE MONIQUE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MONIQUE
Last Name:GOMES
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:PO BOX 46
Mailing Address - Street 2:
Mailing Address - City:NORTH LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:12967-0046
Mailing Address - Country:US
Mailing Address - Phone:315-212-8286
Mailing Address - Fax:
Practice Address - Street 1:1964 STATE HIGHWAY 11C
Practice Address - Street 2:
Practice Address - City:NORTH LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:12967
Practice Address - Country:US
Practice Address - Phone:315-212-8286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY624316163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice