Healthcare Provider Details

I. General information

NPI: 1548031313
Provider Name (Legal Business Name): STACY GORDON REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3316 MONTROSE AVE
ALEXANDRIA VA
22305-3032
US

IV. Provider business mailing address

3316 MONTROSE AVE
ALEXANDRIA VA
22305-3032
US

V. Phone/Fax

Practice location:
  • Phone: 120-259-0529
  • Fax:
Mailing address:
  • Phone: 703-887-4420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number0001259955
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001259955
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: