Provider Demographics
NPI:1982055091
Name:JORDAN, DIANA (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4002 TECHNOLOGY CTR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2697
Mailing Address - Country:US
Mailing Address - Phone:903-247-0484
Mailing Address - Fax:903-247-0485
Practice Address - Street 1:1101 BAYLOR DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-4410
Practice Address - Country:US
Practice Address - Phone:903-238-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX771214163W00000X
TXAP131322363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse