Provider Demographics
NPI:1083213037
Name:GORDON, JOHANNA R (APN-CNP)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:R
Last Name:GORDON
Suffix:
Gender:F
Credentials:APN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 PFINGSTEN RD STE 1200
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1326
Mailing Address - Country:US
Mailing Address - Phone:847-657-1898
Mailing Address - Fax:
Practice Address - Street 1:2150 PFINGSTEN RD STE 1200
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1326
Practice Address - Country:US
Practice Address - Phone:847-657-1898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2022-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209022285363L00000X
IL041.443500163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse