Provider Demographics
NPI:1124994447
Name:GORDON, KAMAYA
Entity type:Individual
Prefix:
First Name:KAMAYA
Middle Name:
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 1:3622 WHISTLER ST
Mailing Address - Street 2:
Mailing Address - City:WHISTLER
Mailing Address - State:AL
Mailing Address - Zip Code:36612-1444
Mailing Address - Country:US
Mailing Address - Phone:251-648-8357
Mailing Address - Fax:
Practice Address - Street 1:3622 WHISTLER ST
Practice Address - Street 2:
Practice Address - City:WHISTLER
Practice Address - State:AL
Practice Address - Zip Code:36612-1444
Practice Address - Country:US
Practice Address - Phone:251-648-8357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-14
Last Update Date:2025-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9691072390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty