Provider Demographics
NPI:1992978134
Name:SALTERS GORDON, KENYA PATRICE (LPN)
Entity type:Individual
Prefix:MS
First Name:KENYA
Middle Name:PATRICE
Last Name:SALTERS 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 1:2643 MARTIN LUTHER KING JR DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-3808
Mailing Address - Country:US
Mailing Address - Phone:216-324-9510
Mailing Address - Fax:
Practice Address - Street 1:2643 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-3808
Practice Address - Country:US
Practice Address - Phone:216-324-9510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH118615164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2628080Medicaid