Provider Demographics
NPI:1750774725
Name:GORDON, MELVA JEANNE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MELVA
Middle Name:JEANNE
Last Name:GORDON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:818 BRITTANY DRIVE
Mailing Address - Street 2:APT D
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-9477
Mailing Address - Country:US
Mailing Address - Phone:740-357-1505
Mailing Address - Fax:
Practice Address - Street 1:2159 DOGWOOD RIDGE RD
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-9044
Practice Address - Country:US
Practice Address - Phone:740-574-2558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-13
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.254002-COA1163W00000X
FLARNP 9400274163W00000X
FLAPRN9400274208D00000X
FL9400274363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice