Provider Demographics
NPI:1164616694
Name:FORDHAM, IRIS DENISE (LPN)
Entity Type:Individual
Prefix:MS
First Name:IRIS
Middle Name:DENISE
Last Name:FORDHAM
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 1:950 LANEY WALKER BLVD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2960
Mailing Address - Country:US
Mailing Address - Phone:706-721-5931
Mailing Address - Fax:
Practice Address - Street 1:950 LANEY WALKER BLVD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2960
Practice Address - Country:US
Practice Address - Phone:706-721-5931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN040000164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse