Provider Demographics
NPI:1427338748
Name:JORDAN, MICHELLE V (CPNP-AC/PC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:V
Last Name:JORDAN
Suffix:
Gender:F
Credentials:CPNP-AC/PC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:VALERIE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:P O BOX 601888
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1888
Mailing Address - Country:US
Mailing Address - Phone:704-403-2662
Mailing Address - Fax:704-403-2670
Practice Address - Street 1:927 45TH ST
Practice Address - Street 2:STE 301
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407
Practice Address - Country:US
Practice Address - Phone:561-227-9240
Practice Address - Fax:561-842-9570
Is Sole Proprietor?:No
Enumeration Date:2011-08-17
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9490043363LP0200X
NC5005260363L00000X, 363LP0200X
NC221553363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2803Medicaid
NC1427338748Medicaid
NCNCG970AMedicare PIN