Healthcare Provider Details

I. General information

NPI: 1912183245
Provider Name (Legal Business Name): NELLA MONICA JORDAN R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 JUANITA AVE
HUNTINGTON NY
11743-5529
US

IV. Provider business mailing address

10 JUANITA AVE
HUNTINGTON NY
11743-5529
US

V. Phone/Fax

Practice location:
  • Phone: 631-425-5113
  • Fax:
Mailing address:
  • Phone: 631-425-5113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number3857421
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number3857421
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: