Healthcare Provider Details

I. General information

NPI: 1740857325
Provider Name (Legal Business Name): KEEMAH GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9700 STONESTREET RD
LOUISVILLE KY
40272-2884
US

IV. Provider business mailing address

9700 STONESTREET RD
LOUISVILLE KY
40272-2884
US

V. Phone/Fax

Practice location:
  • Phone: 502-995-6600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0400X
TaxonomyRehabilitation Registered Nurse
License Number364SL0600X
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: