Provider Demographics
NPI:1780158089
Name:GORDIE, ANGELA DIANE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:DIANE
Last Name:GORDIE
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 1:6455 163RD DR
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-7640
Mailing Address - Country:US
Mailing Address - Phone:386-590-7417
Mailing Address - Fax:
Practice Address - Street 1:6455 163RD DR
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32060-7640
Practice Address - Country:US
Practice Address - Phone:386-590-7417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-20
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant