Provider Demographics
NPI:1679513451
Name:VAN GORDEN, TRACI J (CFNP)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:J
Last Name:VAN GORDEN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 S LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-1947
Mailing Address - Country:US
Mailing Address - Phone:269-319-8850
Mailing Address - Fax:
Practice Address - Street 1:104 S LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-1947
Practice Address - Country:US
Practice Address - Phone:269-319-8850
Practice Address - Fax:269-464-0101
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704252117363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4888010Medicaid
MI4887990Medicaid
A36090039Medicare ID - Type Unspecified
MI4888010Medicaid