Provider Demographics
NPI:1285202689
Name:GORDON, MCKENNALEE GLORIA (LPN)
Entity Type:Individual
Prefix:
First Name:MCKENNALEE
Middle Name:GLORIA
Last Name:GORDON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WALTER ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12204-1605
Mailing Address - Country:US
Mailing Address - Phone:518-530-0935
Mailing Address - Fax:
Practice Address - Street 1:6 WALTER ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12204-1605
Practice Address - Country:US
Practice Address - Phone:518-530-0935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339537164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse