Provider Demographics
NPI:1295321867
Name:GORDON, AMBER LATRICE
Entity type:Individual
Prefix:MISS
First Name:AMBER
Middle Name:LATRICE
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 1:5645 COBBLESTONE CREEK PL
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2667
Mailing Address - Country:US
Mailing Address - Phone:404-273-6773
Mailing Address - Fax:
Practice Address - Street 1:5645 COBBLESTONE CREEK PL
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-2667
Practice Address - Country:US
Practice Address - Phone:404-273-6773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education