Healthcare Provider Details

I. General information

NPI: 1245911858
Provider Name (Legal Business Name): MISS BRIDGET NICOLE GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 04/28/2024
Certification Date: 04/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 N 2ND ST STE 100
RICHMOND KY
40475-1408
US

IV. Provider business mailing address

4903 CROSSING SPRING WAY UNIT 204
LOUISVILLE KY
40229-1189
US

V. Phone/Fax

Practice location:
  • Phone: 502-595-8908
  • Fax:
Mailing address:
  • Phone: 502-922-6653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number219767
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number2393
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: