Healthcare Provider Details

I. General information

NPI: 1326035270
Provider Name (Legal Business Name): VICKI LEE GORDON RN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: VICKI LEE VANIER RN NP

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 W 9 MILE RD DEPT OF SURGERY
SOUTHFIELD MI
48075-4818
US

IV. Provider business mailing address

25925 TELEGRAPH RD 210
SOUTHFIELD MI
48034-2518
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-3000
  • Fax:
Mailing address:
  • Phone: 248-746-0342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number4704147901
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: