Provider Demographics
NPI:1164069720
Name:GORDON, AMY HILARY (CNM)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:HILARY
Last Name:GORDON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14731 MADISON PL
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33325-3039
Mailing Address - Country:US
Mailing Address - Phone:508-292-8095
Mailing Address - Fax:
Practice Address - Street 1:1625 SE 3RD AVE # 502
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2521
Practice Address - Country:US
Practice Address - Phone:954-581-8706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11005201363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner