Provider Demographics
NPI:1235628637
Name:GATHERS, IRIS LEVON (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:LEVON
Last Name:GATHERS
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1142
Mailing Address - Street 2:
Mailing Address - City:PORT ST JOE
Mailing Address - State:FL
Mailing Address - Zip Code:32457-1142
Mailing Address - Country:US
Mailing Address - Phone:850-227-6029
Mailing Address - Fax:
Practice Address - Street 1:200 REID AVE
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1824
Practice Address - Country:US
Practice Address - Phone:850-229-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL17092700007531744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management