MEDICARE: LOLA ZAYKEEAH GORDON LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN.131935-M-IV	OH
2	164W00000X	Licensed Practical Nurse	4703103360	MI

General Provider Information

NPI Number	:	1740574896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOLA ZAYKEEAH GORDON LPN

Provider Business Mailing Address
First Line	:	2647 GLENBRIAR ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-4669
Country	:	US
Telephone Number	:	614-551-9845
Fax Number	:

Provider Business Practice Location Address
First Line	:	2647 GLENBRIAR ST
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-4669
Country	:	US
Telephone Number	:	614-551-9845
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2011
Last Update Date	:	06/07/2011

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