Provider Demographics
NPI:1184180093
Name:GORDON, KELLROY
Entity Type:Individual
Prefix:
First Name:KELLROY
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 MALABAR RD SW APT 202
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-2992
Mailing Address - Country:US
Mailing Address - Phone:321-614-5082
Mailing Address - Fax:
Practice Address - Street 1:530 MALABAR RD SW APT 202
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2992
Practice Address - Country:US
Practice Address - Phone:321-614-5082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372500000X, 374700000X, 3747P1801X, 376J00000X, 376K00000X
FL195341372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No372500000XNursing Service Related ProvidersChore Provider
No374700000XNursing Service Related ProvidersTechnician
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide