Provider Demographics
NPI:1174800643
Name:GORDON, KELLEY (LPN)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 FERRY ST
Mailing Address - Street 2:# 6
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-5608
Mailing Address - Country:US
Mailing Address - Phone:617-785-4812
Mailing Address - Fax:
Practice Address - Street 1:321 FERRY ST
Practice Address - Street 2:# 6
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-5608
Practice Address - Country:US
Practice Address - Phone:617-785-4812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN69985164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse