Provider Demographics
NPI:1861194029
Name:GORDON, SHANTAE
Entity type:Individual
Prefix:
First Name:SHANTAE
Middle Name:
Last Name:GORDON
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 1:2320 N CAPITOL ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-1106
Mailing Address - Country:US
Mailing Address - Phone:202-607-4050
Mailing Address - Fax:
Practice Address - Street 1:1434 SARATOGA AVE NE APT 3
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-1909
Practice Address - Country:US
Practice Address - Phone:202-300-0947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant