Provider Demographics
NPI:1861584401
Name:GRIFFIN, GORDAYNE E (FNP)
Entity type:Individual
Prefix:
First Name:GORDAYNE
Middle Name:E
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:GORDAYNE
Other - Middle Name:
Other - Last Name:EGBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10414
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-0414
Mailing Address - Country:US
Mailing Address - Phone:800-632-6074
Mailing Address - Fax:
Practice Address - Street 1:706 PINEYWOOD RD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-2753
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:866-341-7509
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRN034545163WP0809X
NC200735363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00229542OtherRR MEDICARE # - PARADIGM
NCP00229542OtherRR MEDICARE # - PARADIGM
NCS65773Medicare UPIN