Provider Demographics
NPI:1447723796
Name:GOMEZ, BLAKE KATHLEEN (CPNP-AC)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:KATHLEEN
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:BLAKE
Other - Middle Name:KATHLEEN
Other - Last Name:WINCENTSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10860 KINGSBOROUGH TRL
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4660
Mailing Address - Country:US
Mailing Address - Phone:651-769-5002
Mailing Address - Fax:
Practice Address - Street 1:2525 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4518
Practice Address - Country:US
Practice Address - Phone:612-813-7888
Practice Address - Fax:612-813-6361
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209018598363LP0222X
MN8198363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care