Healthcare Provider Details

I. General information

NPI: 1689495269
Provider Name (Legal Business Name): KIERSTEN MALEAH GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1881 UNIVERSITY DR
VIRGINIA BEACH VA
23453-8083
US

IV. Provider business mailing address

9821 RESEARCH DR APT 2103
CHARLOTTE NC
28262-5664
US

V. Phone/Fax

Practice location:
  • Phone: 757-683-4297
  • Fax: 757-683-5253
Mailing address:
  • Phone: 804-687-4649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number360954
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: