Provider Demographics
NPI:1194950204
Name:VAN GORDEN, REGINA (RN, APNP, PMHNP)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:VAN GORDEN
Suffix:
Gender:F
Credentials:RN, APNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N GRAND AVE # 101
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-4984
Mailing Address - Country:US
Mailing Address - Phone:262-300-4948
Mailing Address - Fax:
Practice Address - Street 1:403 N GRAND AVE # 101
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-4984
Practice Address - Country:US
Practice Address - Phone:262-300-4948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI151058-30163W00000X
WI13738363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse