Provider Demographics
NPI:1134621840
Name:GORDON, VICTORIA LENORE (CNM)
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:LENORE
Last Name:GORDON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3338 COUNTRY CLUB RD
Mailing Address - Street 2:STE L1 PMB 252
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-4954
Mailing Address - Country:US
Mailing Address - Phone:229-234-2505
Mailing Address - Fax:229-600-2021
Practice Address - Street 1:14501 SAN PABLO DR N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2857
Practice Address - Country:US
Practice Address - Phone:404-449-4469
Practice Address - Fax:229-600-2021
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-08
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN217011367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty