Provider Demographics
NPI:1932710274
Name:GORDON, TAMMY JOLENE
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:JOLENE
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 1:501 WILSON LN
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-5216
Mailing Address - Country:US
Mailing Address - Phone:304-636-9326
Mailing Address - Fax:
Practice Address - Street 1:249 SMITH AVE LOT 16B
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-9663
Practice Address - Country:US
Practice Address - Phone:304-636-9326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant