Provider Demographics
NPI:1326035270
Name:GORDON, VICKI LEE (RN NP)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:LEE
Last Name:GORDON
Suffix:
Gender:F
Credentials:RN NP
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:LEE
Other - Last Name:VANIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN NP
Mailing Address - Street 1:25925 TELEGRAPH RD
Mailing Address - Street 2:210
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-2518
Mailing Address - Country:US
Mailing Address - Phone:248-746-0342
Mailing Address - Fax:
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:DEPT OF SURGERY
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704147901163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704147901OtherLICENSE