Provider Demographics
NPI:1073531349
Name:GORDON, SHIRLEY (RN)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9975 DWAYNE CT
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-7252
Mailing Address - Country:US
Mailing Address - Phone:440-354-1553
Mailing Address - Fax:440-354-1553
Practice Address - Street 1:9975 DWAYNE CT
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-7252
Practice Address - Country:US
Practice Address - Phone:440-354-1553
Practice Address - Fax:440-354-1553
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN194973163WC0200X, 163WE0003X, 163WH0200X, 163WI0500X, 163WP0200X, 163WS0200X
OHRN 194973163WC3500X, 163WG0000X, 163WM0705X, 163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Not Answered163WC3500XNursing Service ProvidersRegistered NurseCardiac Rehabilitation
Not Answered163WE0003XNursing Service ProvidersRegistered NurseEmergency
Not Answered163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Not Answered163WH0200XNursing Service ProvidersRegistered NurseHome Health
Not Answered163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
Not Answered163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Not Answered163WP0200XNursing Service ProvidersRegistered NursePediatrics
Not Answered163WS0200XNursing Service ProvidersRegistered NurseSchool
Not Answered163WW0000XNursing Service ProvidersRegistered NurseWound Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2171582Medicaid