Provider Demographics
NPI:1861748097
Name:JORDAN, SHA'VONNA M (RN)
Entity type:Individual
Prefix:
First Name:SHA'VONNA
Middle Name:M
Last Name:JORDAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:458 24TH ST
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14303-1844
Mailing Address - Country:US
Mailing Address - Phone:716-990-6084
Mailing Address - Fax:
Practice Address - Street 1:274 MILLICENT AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-2985
Practice Address - Country:US
Practice Address - Phone:171-699-0608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-25
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY605862-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse