Provider Demographics
NPI:1538611132
Name:ANDERSON, EDNA
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:
Last Name:ANDERSON
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 1:18553 KULDIN AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-7565
Mailing Address - Country:US
Mailing Address - Phone:941-249-2581
Mailing Address - Fax:
Practice Address - Street 1:18553 KULDIN AVE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-7565
Practice Address - Country:US
Practice Address - Phone:941-249-2581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-29
Last Update Date:2016-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL032016-21376J00000X
FLCNA102001376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No376J00000XNursing Service Related ProvidersHomemaker