Provider Demographics
NPI:1942405873
Name:GORDON, MARY ELLEN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 N BRIGHTLEAF BLVD STE 1202
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-4486
Mailing Address - Country:US
Mailing Address - Phone:919-934-4997
Mailing Address - Fax:919-934-9280
Practice Address - Street 1:514 N BRIGHTLEAF BLVD STE 1202
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4486
Practice Address - Country:US
Practice Address - Phone:919-934-4997
Practice Address - Fax:919-934-9280
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter