=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689471518
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KOURTNEY GORDON MS,RD/LD,CEDRD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2025
-----------------------------------------------------
Last Update Date | 02/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3314 HENDERSON BLVD STE 206
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33609-2934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-906-7707
-----------------------------------------------------
Fax | 813-502-0266
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3314 HENDERSON BLVD STE 206
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33609-2934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-906-7707
-----------------------------------------------------
Fax | 813-502-0266
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------