Provider Demographics
NPI:1790900108
Name:GORDON, LISA TONNETTE (RN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:TONNETTE
Last Name:GORDON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9045 ALLENSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-3744
Mailing Address - Country:US
Mailing Address - Phone:410-218-1579
Mailing Address - Fax:
Practice Address - Street 1:3525 RESOURCE DR
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-4733
Practice Address - Country:US
Practice Address - Phone:410-887-0607
Practice Address - Fax:410-496-9398
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR111440163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health