Provider Demographics
NPI:1477341618
Name:GORDON, KELLEY LACEY (RN)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:LACEY
Last Name:GORDON
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 HUNTINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-5825
Mailing Address - Country:US
Mailing Address - Phone:916-508-5186
Mailing Address - Fax:
Practice Address - Street 1:1965 BIRKMONT DR
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95742-6407
Practice Address - Country:US
Practice Address - Phone:916-294-9120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA670085163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WS0200XNursing Service ProvidersRegistered NurseSchoolGroup - Single Specialty