Provider Demographics
NPI:1780647586
Name:GORDON, DAWNELLE MARIE-VARGAS (PMHNP-BC, ARNP, APNP)
Entity Type:Individual
Prefix:
First Name:DAWNELLE
Middle Name:MARIE-VARGAS
Last Name:GORDON
Suffix:
Gender:F
Credentials:PMHNP-BC, ARNP, APNP
Other - Prefix:
Other - First Name:DAWNELLE
Other - Middle Name:MARIE
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, PMHNP-BC
Mailing Address - Street 1:2150 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3706
Mailing Address - Country:US
Mailing Address - Phone:312-942-5375
Mailing Address - Fax:
Practice Address - Street 1:2150 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3706
Practice Address - Country:US
Practice Address - Phone:312-942-5375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005943363LP0808X, 363L00000X
IAG-113375363LP0808X
WI7345-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA11851721OtherCAQH
IAQ72823Medicare UPIN