Healthcare Provider Details

I. General information

NPI: 1235819038
Provider Name (Legal Business Name): JORDAN LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2023
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

4605 FAIRVIEW DR APT 341
WILMINGTON NC
28412-3678
US

V. Phone/Fax

Practice location:
  • Phone: 910-667-7000
  • Fax:
Mailing address:
  • Phone: 610-927-7747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number5018481
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: