Provider Demographics
NPI:1396989737
Name:GORDON, LYDIA C
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:C
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 1:1200 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT
Mailing Address - State:WV
Mailing Address - Zip Code:25550-1317
Mailing Address - Country:US
Mailing Address - Phone:304-675-4540
Mailing Address - Fax:
Practice Address - Street 1:1200 MAIN ST
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-1317
Practice Address - Country:US
Practice Address - Phone:304-675-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV36983163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse