Provider Demographics
NPI:1972805422
Name:GORDON, REBECCA (RN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4774 CARTER RD
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-9125
Mailing Address - Country:US
Mailing Address - Phone:585-388-7732
Mailing Address - Fax:585-388-7451
Practice Address - Street 1:190 LONGRIDGE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-3552
Practice Address - Country:US
Practice Address - Phone:585-966-5805
Practice Address - Fax:585-581-8105
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY327618-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse