Provider Demographics
NPI:1376601351
Name:JORDAN-LEWIS, BETH NICHOLE (CRNA, AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:NICHOLE
Last Name:JORDAN-LEWIS
Suffix:
Gender:F
Credentials:CRNA, AGACNP-BC
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:NICHOLE
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA, AGACNP-BC
Mailing Address - Street 1:5380 TECH DATA DR STE 101
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-3122
Mailing Address - Country:US
Mailing Address - Phone:727-431-7241
Mailing Address - Fax:
Practice Address - Street 1:980 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-7072
Practice Address - Country:US
Practice Address - Phone:727-733-4610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN091777163W00000X
TNAPN11845363LA2100X, 363LG0600X, 367500000X
FLAPRN9467487363LA2100X, 363LG0600X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3636462Medicaid
TN4117686OtherBLUE CROSS BLUE SHIELD TN
TNP00441410OtherRAILROAD MEDICARE
TN3636462Medicare PIN
AL009933517Medicaid
GAN356073OtherWELLCARE (GA MEDICAID)
TN3636462Medicare PIN