Provider Demographics
NPI:1689784084
Name:GORDON, JULIA (CRNP)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 S PINEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WALNUT HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32568-1421
Mailing Address - Country:US
Mailing Address - Phone:251-368-9136
Mailing Address - Fax:
Practice Address - Street 1:5811 JACK SPRINGS RD
Practice Address - Street 2:
Practice Address - City:ATMORE
Practice Address - State:AL
Practice Address - Zip Code:36502-5025
Practice Address - Country:US
Practice Address - Phone:251-368-8630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-075175363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-075175OtherRN LICENSE NUMBER
AL631900010Medicaid
S08228Medicare UPIN