Healthcare Provider Details

I. General information

NPI: 1053757344
Provider Name (Legal Business Name): ELOISE MIEKLE GORDON-MALLETT RN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 09/11/2025
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 10TH AVE
NEW YORK NY
10019-1147
US

IV. Provider business mailing address

222 EVERETT PL
ENGLEWOOD NJ
07631-1660
US

V. Phone/Fax

Practice location:
  • Phone: 212-636-3443
  • Fax: 212-523-8189
Mailing address:
  • Phone: 201-871-4226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number440265
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: