Provider Demographics
NPI:1174992127
Name:GORDON, STEPHANIE (CNM)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:D
Other - Last Name:MOLLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN,CNM
Mailing Address - Street 1:611 W. PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:912 N HENRIETTA ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1788
Practice Address - Country:US
Practice Address - Phone:217-342-3337
Practice Address - Fax:217-347-3328
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.013249367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife