Healthcare Provider Details

I. General information

NPI: 1083753644
Provider Name (Legal Business Name): AMY NICOLE GORDON LM, MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6002 WESTGATE BLVD SUITE 120
TACOMA WA
98406-2570
US

IV. Provider business mailing address

820 N 3RD ST APT. E
TACOMA WA
98403-1934
US

V. Phone/Fax

Practice location:
  • Phone: 253-312-9472
  • Fax:
Mailing address:
  • Phone: 253-213-9472
  • Fax: 253-752-6245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMW00000264
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: