=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649006016
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONICA RENEE GORDON RN, BSN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2024
-----------------------------------------------------
Last Update Date | 09/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1411 E 31ST ST
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94602-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-437-4000
-----------------------------------------------------
Fax | 510-437-5173
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2521 MARINER RD
-----------------------------------------------------
City | OAKLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94561-5031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-298-9471
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WW0101X
-----------------------------------------------------
Taxonomy Name | Ambulatory Women's Health Care Registered Nurse
-----------------------------------------------------
License Number | 556721
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------