Provider Demographics
NPI:1366790578
Name:GORDON, LATOYA AMANDA
Entity type:Individual
Prefix:
First Name:LATOYA
Middle Name:AMANDA
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 1:18A DEKALB AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1606
Mailing Address - Country:US
Mailing Address - Phone:631-316-7893
Mailing Address - Fax:
Practice Address - Street 1:18A DEKALB AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1606
Practice Address - Country:US
Practice Address - Phone:631-316-7893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301688-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse