Provider Demographics
NPI:1912545393
Name:GORDON, KANISHIA (HAIR REPL SPECIALIST)
Entity Type:Individual
Prefix:
First Name:KANISHIA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:HAIR REPL SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 CLEARSTREAM OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-4438
Mailing Address - Country:US
Mailing Address - Phone:203-565-5872
Mailing Address - Fax:
Practice Address - Street 1:519 MEMORIAL DR SE STE 209
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-2286
Practice Address - Country:US
Practice Address - Phone:404-836-3845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist