Provider Demographics
NPI:1356459432
Name:GORDON-SMITH, ZYRA DONNANIECE (DNP, APN, CS-FNP)
Entity Type:Individual
Prefix:MRS
First Name:ZYRA
Middle Name:DONNANIECE
Last Name:GORDON-SMITH
Suffix:
Gender:F
Credentials:DNP, APN, CS-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 288080
Mailing Address - Street 2:9718 S. HALSTED
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628
Mailing Address - Country:US
Mailing Address - Phone:773-233-4100
Mailing Address - Fax:773-233-8542
Practice Address - Street 1:9718 S. HALSTED
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628
Practice Address - Country:US
Practice Address - Phone:773-233-4100
Practice Address - Fax:773-233-8542
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041204964363LF0000X
IL209.001637363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209.001637Medicaid
IL041204964Medicaid
Q12367Medicare UPIN