Provider Demographics
NPI:1649529025
Name:GORDON, CARLENE
Entity type:Individual
Prefix:MRS
First Name:CARLENE
Middle Name:
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 1:121 COURTHOUSE LN
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:VA
Mailing Address - Zip Code:22427-9336
Mailing Address - Country:US
Mailing Address - Phone:804-633-5840
Mailing Address - Fax:804-633-4438
Practice Address - Street 1:125 OLDE GREENWICH DRIVE
Practice Address - Street 2:SUITE 220
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-4010
Practice Address - Country:US
Practice Address - Phone:540-898-8001
Practice Address - Fax:540-898-2127
Is Sole Proprietor?:No
Enumeration Date:2012-08-31
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024170186363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily