Healthcare Provider Details

I. General information

NPI: 1871048470
Provider Name (Legal Business Name): KONWRE GORDON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21040 GREENFIELD RD
OAK PARK MI
48237-3025
US

IV. Provider business mailing address

21040 GREENFIELD RD
OAK PARK MI
48237-3025
US

V. Phone/Fax

Practice location:
  • Phone: 248-967-6500
  • Fax: 248-967-6528
Mailing address:
  • Phone: 248-967-6500
  • Fax: 313-875-5617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704257255
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022974
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: