Provider Demographics
NPI:1699598771
Name:GORDON, SHENNEL
Entity type:Individual
Prefix:
First Name:SHENNEL
Middle Name:
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 1:110 COLISEUM XING # 6071
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5971
Mailing Address - Country:US
Mailing Address - Phone:718-285-1155
Mailing Address - Fax:
Practice Address - Street 1:110 COLISEUM XING # 6071
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5971
Practice Address - Country:US
Practice Address - Phone:718-285-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2025-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374700000XNursing Service Related ProvidersTechnicianGroup - Single Specialty