Provider Demographics
NPI:1538848429
Name:GORE, DEJA MONE
Entity type:Individual
Prefix:
First Name:DEJA
Middle Name:MONE
Last Name:GORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 RUSTY LN APT 43
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-8287
Mailing Address - Country:US
Mailing Address - Phone:318-497-5713
Mailing Address - Fax:
Practice Address - Street 1:2300 RUSTY LN APT 43
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-8287
Practice Address - Country:US
Practice Address - Phone:318-497-5173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator