Provider Demographics
NPI:1780155291
Name:EDELEN, KEVIN (NP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:EDELEN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-4855
Mailing Address - Fax:
Practice Address - Street 1:7607 NC HIGHWAY 68 N STE B
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:NC
Practice Address - Zip Code:27310-8803
Practice Address - Country:US
Practice Address - Phone:336-643-3378
Practice Address - Fax:336-643-3670
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011419363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily