Provider Demographics
NPI:1114301140
Name:GORDON, DEIDRE ALLISON (LPN)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:ALLISON
Last Name:GORDON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 CARPENTER RD
Mailing Address - Street 2:APT 1
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-4061
Mailing Address - Country:US
Mailing Address - Phone:225-301-6616
Mailing Address - Fax:
Practice Address - Street 1:5905 CARPENTER RD
Practice Address - Street 2:APT 1
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4061
Practice Address - Country:US
Practice Address - Phone:225-301-6616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20100280164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse