Basic Information
| Provider Information | |||||||||
| NPI: | 1770721102 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1604 VISA DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617612195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098474716 | ||||||||
| FaxNumber: | 3094541107 | ||||||||
| Practice Location | |||||||||
| Address1: | 1604 VISA DR STE 1 | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617612195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098474716 | ||||||||
| FaxNumber: | 3094541107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2009 | ||||||||
| LastUpdateDate: | 01/22/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041326108 | IL | Y | Nursing Service Providers | Registered Nurse |
No ID Information.