Provider Demographics
NPI:1891312948
Name:GORDON, COURTNEY RAE (NP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:RAE
Last Name:GORDON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:RAE
Other - Last Name:HOUSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 ORCHARD PARK
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-5135
Mailing Address - Country:US
Mailing Address - Phone:601-281-0456
Mailing Address - Fax:
Practice Address - Street 1:410 ORCHARD PARK
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5135
Practice Address - Country:US
Practice Address - Phone:601-281-0456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-05
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903982363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner