Provider Demographics
NPI:1871048470
Name:GORDON, KONWRE (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:KONWRE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21040 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-3025
Mailing Address - Country:US
Mailing Address - Phone:248-967-6500
Mailing Address - Fax:313-875-5617
Practice Address - Street 1:21040 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-3025
Practice Address - Country:US
Practice Address - Phone:248-967-6500
Practice Address - Fax:248-967-6528
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704257255363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily