MEDICARE: DAWNELLE MARIE-VARGAS GORDON PMHNP-BC, ARNP, APNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209005943	IL
2	363L00000X	Nurse Practitioner	209005943	IL
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	G-113375	IA
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	7345-33	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11851721	OTHER	IA	CAQH

General Provider Information

NPI Number	:	1780647586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAWNELLE MARIE-VARGAS GORDON PMHNP-BC, ARNP, APNP

Provider Business Mailing Address
First Line	:	2150 W HARRISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3706
Country	:	US
Telephone Number	:	312-942-5375
Fax Number	:

Provider Business Practice Location Address
First Line	:	2150 W HARRISON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3706
Country	:	US
Telephone Number	:	312-942-5375
Fax Number	:

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

Provider Enumeration Date	:	04/11/2006
Last Update Date	:	04/05/2022

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