Provider Demographics
NPI:1588268205
Name:GORDON, COLLIE AINSWORTH
Entity type:Individual
Prefix:
First Name:COLLIE
Middle Name:AINSWORTH
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:779 DREW ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11208-4789
Mailing Address - Country:US
Mailing Address - Phone:718-348-4105
Mailing Address - Fax:
Practice Address - Street 1:125 STUYVESANT AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-1909
Practice Address - Country:US
Practice Address - Phone:718-574-3126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY593873163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse