Provider Demographics
NPI:1083654768
Name:GORDON, STARLA JEAN
Entity Type:Individual
Prefix:
First Name:STARLA
Middle Name:JEAN
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 1:275 SOMERSET LOOP
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372
Mailing Address - Country:US
Mailing Address - Phone:731-695-1086
Mailing Address - Fax:
Practice Address - Street 1:275 SOMERSET LOOP
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372-7713
Practice Address - Country:US
Practice Address - Phone:731-695-1086
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program