Provider Demographics
NPI:1548031313
Name:GORDON, STACY (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22305-3032
Mailing Address - Country:US
Mailing Address - Phone:703-887-4420
Mailing Address - Fax:
Practice Address - Street 1:3316 MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22305-3032
Practice Address - Country:US
Practice Address - Phone:120-259-0529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001259955171400000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No171400000XOther Service ProvidersHealth & Wellness Coach