Provider Demographics
NPI:1164078739
Name:GORDON, RONDELL
Entity Type:Individual
Prefix:
First Name:RONDELL
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 1:7504 WILDER AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32208-4272
Mailing Address - Country:US
Mailing Address - Phone:904-525-4296
Mailing Address - Fax:606-769-1459
Practice Address - Street 1:7504 WILDER AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-4272
Practice Address - Country:US
Practice Address - Phone:904-525-4296
Practice Address - Fax:606-769-1459
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-10
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL372600000X, 372500000X, 374U00000X, 376J00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No372600000XNursing Service Related ProvidersAdult Companion
No372500000XNursing Service Related ProvidersChore Provider
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker