Provider Demographics
NPI:1184088510
Name:SMITH, GORDANA
Entity type:Individual
Prefix:
First Name:GORDANA
Middle Name:
Last Name:SMITH
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 1:5287 CYPRESS LINKS BLVD
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:FL
Mailing Address - Zip Code:32033-4044
Mailing Address - Country:US
Mailing Address - Phone:904-238-1000
Mailing Address - Fax:
Practice Address - Street 1:150 KENT RD STE 2A
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6485
Practice Address - Country:US
Practice Address - Phone:904-238-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3712171100000X
FL53210225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist