Provider Demographics
NPI:1053838649
Name:JORDAN, MELANIE TRUESDALE (FNP-C)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:TRUESDALE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:ELAINE
Other - Last Name:TRUESDALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:115 N SUMTER ST STE 400
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4971
Practice Address - Country:US
Practice Address - Phone:803-774-9465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4789Medicaid