Healthcare Provider Details

I. General information

NPI: 1780148056
Provider Name (Legal Business Name): DANIELLE ALEXIS GORDON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 PALM AVE
IMPERIAL BEACH CA
91932-1229
US

IV. Provider business mailing address

1244 EL CORTEZ CT
CHULA VISTA CA
91910-8186
US

V. Phone/Fax

Practice location:
  • Phone: 619-423-3774
  • Fax:
Mailing address:
  • Phone: 904-631-2880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number95010963
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95010963
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: