Basic Information
| Provider Information | |||||||||
| NPI: | 1982204178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | DOMINIQUE | ||||||||
| MiddleName: | SIMONE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, APRN, NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 E NEW HAVEN AVE STE 11 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329015474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217244545 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 720 E NEW HAVEN AVE STE 11 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329015474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217244545 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2020 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 9417162 | FL | N | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | 363LF0000X | 11014427 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.