Healthcare Provider Details

I. General information

NPI: 1417680604
Provider Name (Legal Business Name): JORDAN LYNN SAMPOGNA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 NEW HANOVER MEDICAL PARK DR
WILMINGTON NC
28403-5345
US

IV. Provider business mailing address

PO BOX 936857
ATLANTA GA
31193-6857
US

V. Phone/Fax

Practice location:
  • Phone: 910-662-9300
  • Fax: 910-662-9301
Mailing address:
  • Phone: 910-662-9300
  • Fax: 910-662-9301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5016490
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSAMP-4O65L
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: