MEDICARE: SHELLY GORDON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1169111	TX

General Provider Information

NPI Number	:	1366386146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLY GORDON

Provider Business Mailing Address
First Line	:	319 EDGEWOOD DR
Second Line	:
City	:	COPPELL
State	:	TX
Zip	:	75019-5806
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6255 GRANBURY RD
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76133-3401
Country	:	US
Telephone Number	:	972-242-4440
Fax Number	:	972-242-4949

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2026
Last Update Date	:	04/14/2026

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Directions to “ SHELLY GORDON ” Practice Location

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