Provider Demographics
NPI:1093196537
Name:GORDON-PRIMUS, KEISHA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:
Last Name:GORDON-PRIMUS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 4TH ST N STE 300
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4399
Mailing Address - Country:US
Mailing Address - Phone:407-863-4048
Mailing Address - Fax:407-987-6560
Practice Address - Street 1:7901 4TH ST N STE 300
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4399
Practice Address - Country:US
Practice Address - Phone:407-863-4048
Practice Address - Fax:407-987-6560
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9231746363LF0000X
FLAPRN9231746363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily