Provider Demographics
NPI:1245407709
Name:GORDON, KIMBERLY ROCHELLE (SURGICAL ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ROCHELLE
Last Name:GORDON
Suffix:
Gender:F
Credentials:SURGICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7309
Mailing Address - Country:US
Mailing Address - Phone:309-242-6439
Mailing Address - Fax:
Practice Address - Street 1:3002 GILL ST STE 3
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3438
Practice Address - Country:US
Practice Address - Phone:309-846-4716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant