Provider Demographics
NPI:1821848086
Name:GORDON, MELISSA (MS)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4661 VANALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-5007
Mailing Address - Country:US
Mailing Address - Phone:818-585-0360
Mailing Address - Fax:
Practice Address - Street 1:4661 VANALDEN AVE
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-5007
Practice Address - Country:US
Practice Address - Phone:818-585-0360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist