Healthcare Provider Details

I. General information

NPI: 1982204178
Provider Name (Legal Business Name): DOMINIQUE S GORDON FNP-C, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 BAYSIDE LAKES BLVD SE STE 103
PALM BAY FL
32909-6867
US

IV. Provider business mailing address

3425 BAYSIDE LAKES BLVD SE STE 103
PALM BAY FL
32909-6867
US

V. Phone/Fax

Practice location:
  • Phone: 321-557-3065
  • Fax:
Mailing address:
  • Phone: 321-364-1094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11014427
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11014427
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: