Provider Demographics
NPI:1376862854
Name:GORDON, LAFAYE (LPN)
Entity Type:Individual
Prefix:MS
First Name:LAFAYE
Middle Name:
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 1:7100 W HAMPTON AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-4858
Mailing Address - Country:US
Mailing Address - Phone:414-535-0811
Mailing Address - Fax:414-535-1915
Practice Address - Street 1:7100 W HAMPTON AVE
Practice Address - Street 2:APT 1
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-4858
Practice Address - Country:US
Practice Address - Phone:414-535-0811
Practice Address - Fax:414-535-1915
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI311989-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse