Provider Demographics
NPI:1922356062
Name:GORDON, TEENA MARIA (RN)
Entity Type:Individual
Prefix:MRS
First Name:TEENA
Middle Name:MARIA
Last Name:GORDON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:TEENA
Other - Middle Name:MARIA
Other - Last Name:BARNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:12 FAIRMOUNT ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580
Mailing Address - Country:US
Mailing Address - Phone:718-679-1620
Mailing Address - Fax:
Practice Address - Street 1:12 FAIRMOUNT ST
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-3016
Practice Address - Country:US
Practice Address - Phone:718-679-1620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6209581163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse