Provider Demographics
NPI:1902494404
Name:EDSALL, DEBRA RENEE
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:RENEE
Last Name:EDSALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12519 WETLAND VIEW CT
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:MD
Mailing Address - Zip Code:21625-2714
Mailing Address - Country:US
Mailing Address - Phone:443-496-0174
Mailing Address - Fax:
Practice Address - Street 1:500 CADMUS LN
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-4094
Practice Address - Country:US
Practice Address - Phone:410-820-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-10
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR082588363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care