Provider Demographics
NPI:1356864110
Name:GORDON, STEPHANIE CHRISTINE (LPN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CHRISTINE
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 1:3315 98TH PL
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-5702
Mailing Address - Country:US
Mailing Address - Phone:517-410-9288
Mailing Address - Fax:
Practice Address - Street 1:2216 20TH ST
Practice Address - Street 2:
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-1648
Practice Address - Country:US
Practice Address - Phone:847-445-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.109586164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse