Provider Demographics
NPI:1023623667
Name:GORDON, BARBARA JEAN (STNA)
Entity type:Individual
Prefix:
First Name:BARBARA
Middle Name:JEAN
Last Name:GORDON
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805 RAVENNA AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-8922
Mailing Address - Country:US
Mailing Address - Phone:330-418-8992
Mailing Address - Fax:330-875-3226
Practice Address - Street 1:640 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-1640
Practice Address - Country:US
Practice Address - Phone:330-268-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400702591207374U00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2828784Medicaid