Provider Demographics
NPI:1942940317
Name:GORDON, KRISTY LYNN
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:LYNN
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 1:10859 ROLLING CLOUD DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80908-5232
Mailing Address - Country:US
Mailing Address - Phone:719-399-5502
Mailing Address - Fax:
Practice Address - Street 1:10859 ROLLING CLOUD DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80908-5232
Practice Address - Country:US
Practice Address - Phone:719-399-5502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty