Provider Demographics
NPI:1598329534
Name:GORDON-LOUISON, JUDIE LYN
Entity Type:Individual
Prefix:
First Name:JUDIE
Middle Name:LYN
Last Name:GORDON-LOUISON
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 1:2429 EAST FAYETTE STREET, SYRACUSE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224
Mailing Address - Country:US
Mailing Address - Phone:315-880-6085
Mailing Address - Fax:
Practice Address - Street 1:2429 EAST FAYETTE STREET, SYRACUSE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13224
Practice Address - Country:US
Practice Address - Phone:315-880-6085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY713124163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health