Provider Demographics
NPI:1902456262
Name:EDGLEY, RONDA (NP)
Entity Type:Individual
Prefix:
First Name:RONDA
Middle Name:
Last Name:EDGLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N 3RD AVE STE B
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6306
Mailing Address - Country:US
Mailing Address - Phone:208-646-4165
Mailing Address - Fax:208-646-4195
Practice Address - Street 1:415 N 3RD AVE STE B
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6306
Practice Address - Country:US
Practice Address - Phone:208-646-4165
Practice Address - Fax:208-646-4195
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNP62704363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner