1356459432 NPI number — MRS. ZYRA DONNANIECE GORDON-SMITH DNP, APN, CS-FNP

Table of content: MRS. ZYRA DONNANIECE GORDON-SMITH DNP, APN, CS-FNP (NPI 1356459432)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356459432 NPI number — MRS. ZYRA DONNANIECE GORDON-SMITH DNP, APN, CS-FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON-SMITH
Provider First Name:
ZYRA
Provider Middle Name:
DONNANIECE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DNP, APN, CS-FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356459432
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 288080
Provider Second Line Business Mailing Address:
9718 S. HALSTED
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-233-4100
Provider Business Mailing Address Fax Number:
773-233-8542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9718 S. HALSTED
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-233-4100
Provider Business Practice Location Address Fax Number:
773-233-8542
Provider Enumeration Date:
08/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  041204964 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 209.001637 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 209.001637 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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