Provider Demographics
NPI:1881225613
Name:JORDAN, MEGHAN LEE (APRN)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:LEE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MEGHAN
Other - Middle Name:LEE
Other - Last Name:KUNTZLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1416 BALLARD GREEN PL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-2373
Mailing Address - Country:US
Mailing Address - Phone:813-527-1527
Mailing Address - Fax:
Practice Address - Street 1:2727 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6383
Practice Address - Country:US
Practice Address - Phone:813-515-5782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-30
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11005278363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner