=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164428074
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NINA T JORDANIA MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2005
-----------------------------------------------------
Last Update Date | 03/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6801 PORTO FINO CIR STE 1
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33912-4344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-225-0874
-----------------------------------------------------
Fax | 239-225-1465
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25111 PENNYROYAL DR STE 1
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34134-7944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-740-8375
-----------------------------------------------------
Fax | 630-740-8375
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 036107234
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME126750
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------