Healthcare Provider Details

I. General information

NPI: 1376601351
Provider Name (Legal Business Name): BETH NICHOLE JORDAN-LEWIS CRNA, AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BETH NICHOLE JORDAN CRNA, AGACNP-BC

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/21/2022
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 MILWAUKEE AVE
DUNEDIN FL
34698-7072
US

IV. Provider business mailing address

5380 TECH DATA DR STE 101
CLEARWATER FL
33760-3122
US

V. Phone/Fax

Practice location:
  • Phone: 727-733-4610
  • Fax:
Mailing address:
  • Phone: 727-431-7241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN091777
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPN11845
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN9467487
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN9467487
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPN11845
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN11845
License Number StateTN
# 7
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN9467487
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: