Healthcare Provider Details

I. General information

NPI: 1568264026
Provider Name (Legal Business Name): TREVA LYNETTE GORDON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 03/26/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 TUXEDO ST
HIGHLAND PARK MI
48203-3532
US

IV. Provider business mailing address

49 TUXEDO ST
HIGHLAND PARK MI
48203-3532
US

V. Phone/Fax

Practice location:
  • Phone: 313-657-3558
  • Fax:
Mailing address:
  • Phone: 131-365-7355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704268704
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: