=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326345042
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CANDISE ELAINE JORDAN FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2011
-----------------------------------------------------
Last Update Date | 05/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3850 S NATIONAL AVE SUITE 600
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65807-5287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-882-4880
-----------------------------------------------------
Fax | 417-882-7843
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9160 FORUM CORPORATE PKWY STE 350
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33905-7808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-785-3200
-----------------------------------------------------
Fax | 813-630-6105
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 2011003425
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 2011003425
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------