Basic Information
| Provider Information | |||||||||
| NPI: | 1720217805 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | HALEY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1087 MCLYNN AVE NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303063324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043135833 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1968 PEACHTREE ROAD NW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043511745 | ||||||||
| FaxNumber: | 4043517121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2009 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN165923 | GA | N | Nursing Service Providers | Registered Nurse | 367500000X | RN165923 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 864081803B | 05 | GA | MEDICAID |