=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255066981
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIERSTYN GORDON NURSE PRACTITIONER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2022
-----------------------------------------------------
Last Update Date | 02/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 529 CENTRAL AVE
-----------------------------------------------------
City | DUNKIRK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14048-2599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-363-7344
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3373 OLD FLUVANNA RD STE 1
-----------------------------------------------------
City | FLUVANNA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14701-9047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-397-2291
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F349856-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------