=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093043242
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY M GORDON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2009
-----------------------------------------------------
Last Update Date | 11/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4665 E SUNSET DR
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46567-9168
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-627-8233
-----------------------------------------------------
Fax | 877-710-7891
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 813 N MAIN ST
-----------------------------------------------------
City | AVILLA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46710-9658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-318-2903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | 0500869
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------