Healthcare Provider Details

I. General information

NPI: 1154624161
Provider Name (Legal Business Name): DIANNE JOAN MARIE GORDON REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 12/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

973 UTAH PL
WEST HEMPSTEAD NY
11552-3916
US

IV. Provider business mailing address

973 UTAH PL
WEST HEMPSTEAD NY
11552-3916
US

V. Phone/Fax

Practice location:
  • Phone: 917-327-4200
  • Fax:
Mailing address:
  • Phone: 917-327-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number496373
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number496373
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: