Provider Demographics
NPI:1760032122
Name:GORDON, MICHELLE RENEE (LPN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
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 1:2538 NEDRA AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44305-3930
Mailing Address - Country:US
Mailing Address - Phone:330-760-4444
Mailing Address - Fax:
Practice Address - Street 1:1199 VERNON ODOM BLVD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307-1048
Practice Address - Country:US
Practice Address - Phone:330-873-3396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.142088.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse