Provider Demographics
NPI:1982204178
Name:GORDON, DOMINIQUE S (FNP-C, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:S
Last Name:GORDON
Suffix:
Gender:F
Credentials:FNP-C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-728-6072
Mailing Address - Fax:
Practice Address - Street 1:7000 SPYGLASS CT STE 220
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-7948
Practice Address - Country:US
Practice Address - Phone:321-728-6072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11014427363LF0000X, 363LP0808X
FL9417162163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGOtherMEDICARE HF