Provider Demographics
NPI:1588645444
Name:GORDON, JUDY RAE (RN)
Entity Type:Individual
Prefix:MS
First Name:JUDY
Middle Name:RAE
Last Name:GORDON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:JUDITH
Other - Middle Name:PAULSON
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:1909 W IDAHO AVE
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-1147
Mailing Address - Country:US
Mailing Address - Phone:208-245-2002
Mailing Address - Fax:
Practice Address - Street 1:1100 A ST
Practice Address - Street 2:
Practice Address - City:PLUMMER
Practice Address - State:ID
Practice Address - Zip Code:83851
Practice Address - Country:US
Practice Address - Phone:208-686-1767
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN22901163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse