Provider Demographics
NPI: | 1437590999 |
---|---|
Name: | GORDON, BRIGITTE L (RN) |
Entity Type: | Individual |
Prefix: | MS |
First Name: | BRIGITTE |
Middle Name: | L |
Last Name: | GORDON |
Suffix: | |
Gender: | F |
Credentials: | RN |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 75 CRYSTAL RUN RD STE 135 |
Mailing Address - Street 2: | |
Mailing Address - City: | MIDDLETOWN |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 10941-7009 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 845-333-7800 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 75 CRYSTAL RUN RD STE 135 |
Practice Address - Street 2: | |
Practice Address - City: | MIDDLETOWN |
Practice Address - State: | NY |
Practice Address - Zip Code: | 10941 |
Practice Address - Country: | US |
Practice Address - Phone: | 845-333-7800 |
Practice Address - Fax: | 845-333-7696 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2013-07-12 |
Last Update Date: | 2018-08-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 659845-1 | 163WP0809X |
NY | 40 401775 | 363LP0808X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health |
No | 163WP0809X | Nursing Service Providers | Registered Nurse | Psychiatric/Mental Health, Adult |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 04276486 | Medicaid |