1124871801 NPI number — VIRIDIANA SIMONA VANDENHENGELGOMEZ PA65426

Table of content: LAUREN ALEXANDRA KASHA SMITH APRN (NPI 1952079303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124871801 NPI number — VIRIDIANA SIMONA VANDENHENGELGOMEZ PA65426

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDENHENGELGOMEZ
Provider First Name:
VIRIDIANA
Provider Middle Name:
SIMONA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA65426
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VAN DEN HENGEL-GOMEZ
Provider Other First Name:
VIRIDIANA
Provider Other Middle Name:
SIMONA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA65426
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124871801
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 RALEIGH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VACAVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95687-6636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-787-3454
Provider Business Mailing Address Fax Number:
530-795-3054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
172 E GRANT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTERS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95694-1780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-734-2145
Provider Business Practice Location Address Fax Number:
530-795-3054
Provider Enumeration Date:
04/10/2024

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA65426 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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