Provider Demographics
NPI:1891022182
Name:GORDON, KELLY KATHLEEN (ARNP))
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KATHLEEN
Last Name:GORDON
Suffix:
Gender:F
Credentials:ARNP)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 NW DOGWOOD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-3210
Mailing Address - Country:US
Mailing Address - Phone:800-230-7526
Mailing Address - Fax:425-369-0725
Practice Address - Street 1:75 NW DOGWOOD ST
Practice Address - Street 2:SUITE B
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-3210
Practice Address - Country:US
Practice Address - Phone:800-230-7526
Practice Address - Fax:425-369-0725
Is Sole Proprietor?:No
Enumeration Date:2009-11-08
Last Update Date:2009-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60112317363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health