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NPI Code Detail

MEDICARE: KELLEY LACEY GORDON RN

MEDICARE: KELLEY LACEY GORDON RN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1163WS0200XSchool Registered Nurse670085CA

General Provider Information

NPI Number : 1477341618
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLEY LACEY GORDON RN
Provider Business Mailing Address
First Line : 2139 HUNTINGTON CIR
Second Line :
City : EL DORADO HILLS
State : CA
Zip : 95762-5825
Country : US
Telephone Number : 916-508-5186
Fax Number :
Provider Business Practice Location Address
First Line : 1965 BIRKMONT DR
Second Line :
City : RANCHO CORDOVA
State : CA
Zip : 95742-6407
Country : US
Telephone Number : 916-294-9120
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/28/2025
Last Update Date : 04/28/2025

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