Provider Demographics
NPI:1619712825
Name:GORDON-EDENBURGH, SARETTA LANIECE
Entity type:Individual
Prefix:
First Name:SARETTA
Middle Name:LANIECE
Last Name:GORDON-EDENBURGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SYREETA
Other - Middle Name:LANIECE
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1405 VILLA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-2903
Mailing Address - Country:US
Mailing Address - Phone:216-716-0242
Mailing Address - Fax:
Practice Address - Street 1:1405 VILLA DR
Practice Address - Street 2:
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-2903
Practice Address - Country:US
Practice Address - Phone:216-716-0242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSM696161171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty