Provider Demographics
NPI:1104200013
Name:GORDON, TIFFANIE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:TIFFANIE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 CLINTON ST STE 601
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-4282
Mailing Address - Country:US
Mailing Address - Phone:516-933-0485
Mailing Address - Fax:
Practice Address - Street 1:50 CLINTON ST STE 601
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-4282
Practice Address - Country:US
Practice Address - Phone:516-933-0485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY700298-1251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management