Provider Demographics
NPI:1679247993
Name:GORDON, ALYSSA (DNP, FNP-BC, CNL)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:DNP, FNP-BC, CNL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1437 W GRAND AVE APT 1S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-6318
Mailing Address - Country:US
Mailing Address - Phone:847-650-7235
Mailing Address - Fax:
Practice Address - Street 1:310 W CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-5106
Practice Address - Country:US
Practice Address - Phone:453-530-2725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019777363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily