Provider Demographics
NPI:1093043242
Name:GORDON, TIFFANY M
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
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 1:813 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AVILLA
Mailing Address - State:IN
Mailing Address - Zip Code:46710-9658
Mailing Address - Country:US
Mailing Address - Phone:260-318-2903
Mailing Address - Fax:
Practice Address - Street 1:4665 E SUNSET DR
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:IN
Practice Address - Zip Code:46567-9168
Practice Address - Country:US
Practice Address - Phone:866-627-8233
Practice Address - Fax:877-710-7891
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0500869376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide