Provider Demographics
NPI:1104361732
Name:GORDON, SILAS KENNY (LPN, AAC)
Entity Type:Individual
Prefix:MR
First Name:SILAS
Middle Name:KENNY
Last Name:GORDON
Suffix:
Gender:M
Credentials:LPN, AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3419 REDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1139
Mailing Address - Country:US
Mailing Address - Phone:360-325-9340
Mailing Address - Fax:
Practice Address - Street 1:3419 REDWOOD AVE
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1139
Practice Address - Country:US
Practice Address - Phone:360-325-9340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP60623702164W00000X
WACG61049487106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALP 60623702OtherSTATE NURSING LICENSE