Provider Demographics
NPI:1013138692
Name:GORDON, TONIKA ISEDREIKA
Entity Type:Individual
Prefix:
First Name:TONIKA
Middle Name:ISEDREIKA
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 HANFORD ST.
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206
Mailing Address - Country:US
Mailing Address - Phone:614-449-2103
Mailing Address - Fax:
Practice Address - Street 1:750 HANFORD ST.
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206
Practice Address - Country:US
Practice Address - Phone:614-449-2103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-108308164W00000X
OHRN-410243163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2358792Medicaid