Healthcare Provider Details

I. General information

NPI: 1104200013
Provider Name (Legal Business Name): TIFFANIE GORDON REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 CLINTON ST STE 601
HEMPSTEAD NY
11550-4282
US

IV. Provider business mailing address

50 CLINTON ST STE 601
HEMPSTEAD NY
11550-4282
US

V. Phone/Fax

Practice location:
  • Phone: 516-933-0485
  • Fax:
Mailing address:
  • Phone: 516-933-0485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number700298-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: