1427338748 NPI number — MICHELLE V JORDAN CPNP-AC/PC

Table of content: MICHELLE V JORDAN CPNP-AC/PC (NPI 1427338748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427338748 NPI number — MICHELLE V JORDAN CPNP-AC/PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JORDAN
Provider First Name:
MICHELLE
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPNP-AC/PC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TAYLOR
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
VALERIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1427338748
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 601888
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-1888
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-403-2662
Provider Business Mailing Address Fax Number:
704-403-2670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
927 45TH ST
Provider Second Line Business Practice Location Address:
STE 301
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-227-9240
Provider Business Practice Location Address Fax Number:
561-842-9570
Provider Enumeration Date:
08/17/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  ARNP9490043 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: 5005260 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: 221553 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: 5005260 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NP2803 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1427338748 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101644800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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