Healthcare Provider Details

I. General information

NPI: 1659193928
Provider Name (Legal Business Name): GINA GORDENIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 PARK PLACE CIR STE 200
MISHAWAKA IN
46545-3585
US

IV. Provider business mailing address

515 PARK PLACE CIR STE 200
MISHAWAKA IN
46545-3585
US

V. Phone/Fax

Practice location:
  • Phone: 574-607-4724
  • Fax: 574-607-4725
Mailing address:
  • Phone: 574-607-4724
  • Fax: 574-607-4725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71015969A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number71015969A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: