Provider Demographics
NPI:1578111506
Name:GORDON, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 S KEEL WAY
Mailing Address - Street 2:
Mailing Address - City:PORT LUDLOW
Mailing Address - State:WA
Mailing Address - Zip Code:98365-9542
Mailing Address - Country:US
Mailing Address - Phone:425-894-4494
Mailing Address - Fax:
Practice Address - Street 1:81 S KEEL WAY
Practice Address - Street 2:
Practice Address - City:PORT LUDLOW
Practice Address - State:WA
Practice Address - Zip Code:98365-9542
Practice Address - Country:US
Practice Address - Phone:425-894-4494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider