Healthcare Provider Details

I. General information

NPI: 1164451647
Provider Name (Legal Business Name): DONNA ANITA GORDON AUDIOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DONNA ANITA HART

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 N. FLORIDA AVENUE
LAKELAND FL
33805-3109
US

IV. Provider business mailing address

PO BOX 95004
LAKELAND FL
33804-5004
US

V. Phone/Fax

Practice location:
  • Phone: 863-904-6200
  • Fax: 863-904-6280
Mailing address:
  • Phone: 863-680-7206
  • Fax: 863-680-7420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAY1034
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: