1134621840 NPI number — MRS. VICTORIA LENORE GORDON CNM

Table of content: MRS. VICTORIA LENORE GORDON CNM (NPI 1134621840)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134621840 NPI number — MRS. VICTORIA LENORE GORDON CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
VICTORIA
Provider Middle Name:
LENORE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134621840
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3338 COUNTRY CLUB RD
Provider Second Line Business Mailing Address:
STE L1 PMB 252
Provider Business Mailing Address City Name:
VALDOSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31605-4954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-234-2505
Provider Business Mailing Address Fax Number:
229-600-2021

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14501 SAN PABLO DR N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32224-2857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-449-4469
Provider Business Practice Location Address Fax Number:
229-600-2021
Provider Enumeration Date:
03/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  RN217011 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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