Provider Demographics
NPI:1831785476
Name:GORDON, TEAGHAN MICHELLE LATTANZE
Entity type:Individual
Prefix:MRS
First Name:TEAGHAN
Middle Name:MICHELLE LATTANZE
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 1:9009 CHURCH ST APT 105
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-5473
Mailing Address - Country:US
Mailing Address - Phone:540-359-1772
Mailing Address - Fax:
Practice Address - Street 1:9009 CHURCH ST APT 105
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-5473
Practice Address - Country:US
Practice Address - Phone:540-359-1772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program