MEDICARE: MRS. LENISE MARLENA JORDAN NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN162420	GA

General Provider Information

NPI Number	:	1639595309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LENISE MARLENA JORDAN NP-C

Provider Business Mailing Address
First Line	:	6085 OLD NATIONAL HWY STE G
Second Line	:
City	:	SOUTH FULTON
State	:	GA
Zip	:	30349-4333
Country	:	US
Telephone Number	:	844-644-4325
Fax Number	:	855-583-3678

Provider Business Practice Location Address
First Line	:	6085 OLD NATIONAL HWY STE G
Second Line	:
City	:	SOUTH FULTON
State	:	GA
Zip	:	30349-4333
Country	:	US
Telephone Number	:	844-644-4325
Fax Number	:	855-583-3678

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2014
Last Update Date	:	05/03/2024

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