Provider Demographics
NPI:1568022523
Name:GORDON, KRYSTAL (ARNP)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:ARNP
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1500
Mailing Address - Fax:239-424-1423
Practice Address - Street 1:260 BETH STACEY BLVD # C
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-6074
Practice Address - Country:US
Practice Address - Phone:239-343-9888
Practice Address - Fax:239-303-0714
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002846363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103687500Medicaid