Provider Demographics
NPI:1275167421
Name:GOURDINE, KRISTI T (REGISTERED NURSE)
Entity Type:Individual
Prefix:MS
First Name:KRISTI
Middle Name:T
Last Name:GOURDINE
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 HUNTER AVE APT 24F
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-5629
Mailing Address - Country:US
Mailing Address - Phone:646-528-9604
Mailing Address - Fax:
Practice Address - Street 1:408 E 137TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10454-4004
Practice Address - Country:US
Practice Address - Phone:718-555-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY543258-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse