Provider Demographics
NPI:1982431938
Name:GOMEZ INGUANZO, ANA IRIS
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:IRIS
Last Name:GOMEZ INGUANZO
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 1:6865 NW 169TH ST APT A
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4252
Mailing Address - Country:US
Mailing Address - Phone:786-878-0944
Mailing Address - Fax:
Practice Address - Street 1:6865 NW 169TH ST APT A
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-4252
Practice Address - Country:US
Practice Address - Phone:786-878-0944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-369944106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician