Provider Demographics
NPI:1427342054
Name:GORDON, ANNETTE (RN CLC)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:RN CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5559 REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-3222
Mailing Address - Country:US
Mailing Address - Phone:216-712-0798
Mailing Address - Fax:
Practice Address - Street 1:5559 REDWOOD DR
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-3222
Practice Address - Country:US
Practice Address - Phone:216-712-0798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.240968163WC0400X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRP820172OtherDL