Provider Demographics
NPI:1073744280
Name:GORDON, SHELBY LYNN (NP-C)
Entity type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:LYNN
Last Name:GORDON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:COLQUITT
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 830525
Mailing Address - Street 2:DEPT# OWC 24
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35283-0525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5510 PROMENADE POINT PKWY NW # 160
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-6702
Practice Address - Country:US
Practice Address - Phone:256-289-8470
Practice Address - Fax:256-993-3096
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-163097363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA513630481CMedicaid