Provider Demographics
NPI:1043683360
Name:GORDON-FAHN, LAUREN (LAC)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:GORDON-FAHN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 KENTUCKY ST
Mailing Address - Street 2:SUITE 10
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2305
Mailing Address - Country:US
Mailing Address - Phone:707-774-6595
Mailing Address - Fax:
Practice Address - Street 1:159 KENTUCKY ST
Practice Address - Street 2:SUITE 10
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2305
Practice Address - Country:US
Practice Address - Phone:707-774-6595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16722171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist