Provider Demographics
NPI:1093271041
Name:GORDOM, TAMEKA L
Entity Type:Individual
Prefix:
First Name:TAMEKA
Middle Name:L
Last Name:GORDOM
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 1:803 SHADRACK ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30830-1244
Mailing Address - Country:US
Mailing Address - Phone:706-535-9113
Mailing Address - Fax:
Practice Address - Street 1:803 SHADRACK ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:GA
Practice Address - Zip Code:30830-1244
Practice Address - Country:US
Practice Address - Phone:706-535-9113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA653626174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA83-3582448Medicaid