Provider Demographics
NPI:1407508377
Name:GORDON, DEANNA THALIA
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:THALIA
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 1:1134 SHERMAN AVE NW
Mailing Address - Street 2:
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663-1068
Mailing Address - Country:US
Mailing Address - Phone:330-880-7311
Mailing Address - Fax:
Practice Address - Street 1:1134 SHERMAN AVE NW
Practice Address - Street 2:
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663-1068
Practice Address - Country:US
Practice Address - Phone:330-880-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-21
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide