=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679800643
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLENE MICHELE JORDAN FNP-BC, RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2009
-----------------------------------------------------
Last Update Date | 07/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2955 MARKET ST SUITE 5
-----------------------------------------------------
City | CHRISTIANSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24073-6575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-381-5291
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2013 JEFFERSON ST SW FL 2
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24014-2419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-982-0237
-----------------------------------------------------
Fax | 540-982-2719
-----------------------------------------------------
=====================================================
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 | 0024168446
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------