Provider Demographics
NPI:1134498926
Name:GORDON, CARRIE KALLENBACH (NP)
Entity Type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:KALLENBACH
Last Name:GORDON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 BRADFORD AVENUE
Mailing Address - Street 2:MAGUIRE CORRECTIONAL FACILITY
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063
Mailing Address - Country:US
Mailing Address - Phone:650-363-4241
Mailing Address - Fax:
Practice Address - Street 1:300 BRADFORD STREET
Practice Address - Street 2:MAGUIRE CORRECTIONAL FACILITY
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063
Practice Address - Country:US
Practice Address - Phone:650-363-4241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12246363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily