Provider Demographics
NPI:1073224200
Name:GORDON, SHARONDA
Entity Type:Individual
Prefix:
First Name:SHARONDA
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 1:6941 N TRENHOLM RD STE F104
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-1715
Mailing Address - Country:US
Mailing Address - Phone:803-618-3168
Mailing Address - Fax:
Practice Address - Street 1:203 INDIGO HILLS DR
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-7582
Practice Address - Country:US
Practice Address - Phone:803-618-3168
Practice Address - Fax:803-401-5025
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant