Provider Demographics
NPI:1053757344
Name:GORDON-MALLETT, ELOISE MIEKLE (RN, FNP)
Entity type:Individual
Prefix:
First Name:ELOISE
Middle Name:MIEKLE
Last Name:GORDON-MALLETT
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 EVERETT PL
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-1660
Mailing Address - Country:US
Mailing Address - Phone:201-871-4226
Mailing Address - Fax:
Practice Address - Street 1:1000 10TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1147
Practice Address - Country:US
Practice Address - Phone:212-636-3443
Practice Address - Fax:212-523-8189
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY440265163WC0200X
NYF337206164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF337206OtherNEW YORK STATE NURSE PRACTITIONER LICENSE
NY440265OtherNEW YORK STATE REGISTERED PROFESSIONAL NURSE