Provider Demographics
NPI:1245911858
Name:GORDON, BRIDGET NICOLE
Entity type:Individual
Prefix:MISS
First Name:BRIDGET
Middle Name:NICOLE
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4903 CROSSING SPRING WAY UNIT 204
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-1189
Mailing Address - Country:US
Mailing Address - Phone:502-922-6653
Mailing Address - Fax:
Practice Address - Street 1:212 N 2ND ST STE 100
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-1408
Practice Address - Country:US
Practice Address - Phone:502-595-8908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-27
Last Update Date:2024-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL219767246RP1900X
171400000X, 171W00000X, 106S00000X
IL2393251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No171400000XOther Service ProvidersHealth & Wellness Coach
No171W00000XOther Service ProvidersContractor
No251J00000XAgenciesNursing Care
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21-9767OtherNPCE
IL2393OtherNPCE