Provider Demographics
NPI:1457824393
Name:JORDAN, MIRANDA LYALLS (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:LYALLS
Last Name:JORDAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 WITHERSPOON HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28640-9043
Mailing Address - Country:US
Mailing Address - Phone:336-977-9724
Mailing Address - Fax:
Practice Address - Street 1:310 HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28640
Practice Address - Country:US
Practice Address - Phone:336-846-6322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011326363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1619907334Medicaid