Basic Information
| Provider Information | |||||||||
| NPI: | 1053757344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON-MALLETT | ||||||||
| FirstName: | ELOISE | ||||||||
| MiddleName: | MIEKLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN, FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100191147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126363443 | ||||||||
| FaxNumber: | 2125238189 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100191147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126363443 | ||||||||
| FaxNumber: | 2125238189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2013 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | 440265 | NY | N | Nursing Service Providers | Registered Nurse | Critical Care Medicine | 164W00000X | F337206 | NY | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 440265 | 01 | NY | NEW YORK STATE REGISTERED PROFESSIONAL NURSE | OTHER | F337206 | 01 | NY | NEW YORK STATE NURSE PRACTITIONER LICENSE | OTHER |