Healthcare Provider Details

I. General information

NPI: 1326976523
Provider Name (Legal Business Name): MICHELLE GOURDINE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CVS DR
WOONSOCKET RI
02895-6195
US

IV. Provider business mailing address

1 CVS DR
WOONSOCKET RI
02895-6195
US

V. Phone/Fax

Practice location:
  • Phone: 410-916-7509
  • Fax:
Mailing address:
  • Phone: 410-916-7509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD45056
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: