Provider Demographics
NPI:1376324228
Name:GORDON, ANGELA LASHAWN
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LASHAWN
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 1:5422 1/2 RUTHELEN ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-2529
Mailing Address - Country:US
Mailing Address - Phone:323-208-8597
Mailing Address - Fax:
Practice Address - Street 1:5422 1/2 RUTHELEN ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90062-2529
Practice Address - Country:US
Practice Address - Phone:323-208-8597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC4561135172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver