Healthcare Provider Details

I. General information

NPI: 1033328752
Provider Name (Legal Business Name): NANCY LYNN GORDON-GREEN R.N., M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 MIDDLE TPKE W SUITE #205
MANCHESTER CT
06040-3863
US

IV. Provider business mailing address

483 MIDDLE TPKE W SUITE #205
MANCHESTER CT
06040-3863
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-3382
  • Fax: 860-632-0622
Mailing address:
  • Phone: 860-646-3382
  • Fax: 860-632-0622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberE54252
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: