Provider Demographics
NPI:1194340117
Name:GORDON, TAWANA LAVETTE
Entity type:Individual
Prefix:
First Name:TAWANA
Middle Name:LAVETTE
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8242 DURALEE LN APT 909
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-8507
Mailing Address - Country:US
Mailing Address - Phone:770-324-6799
Mailing Address - Fax:
Practice Address - Street 1:8242 DURALEE LN APT 909
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-8507
Practice Address - Country:US
Practice Address - Phone:770-324-6799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide