Provider Demographics
NPI:1255082509
Name:GORDON, KIMBERLY PANSY FAY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PANSY FAY
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 1:501 WILSON LN
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-5216
Mailing Address - Country:US
Mailing Address - Phone:304-636-9326
Mailing Address - Fax:
Practice Address - Street 1:711 FISHING CAMP RD
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-8451
Practice Address - Country:US
Practice Address - Phone:304-460-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant