Provider Demographics
NPI:1861910721
Name:EDGELL, LETITIA SUSAN
Entity type:Individual
Prefix:MRS
First Name:LETITIA
Middle Name:SUSAN
Last Name:EDGELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LETITIA
Other - Middle Name:SUSAN
Other - Last Name:FORSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:503 LAWNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-4030
Mailing Address - Country:US
Mailing Address - Phone:815-527-7624
Mailing Address - Fax:815-337-2032
Practice Address - Street 1:503 LAWNDALE AVE.
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098
Practice Address - Country:US
Practice Address - Phone:815-527-7624
Practice Address - Fax:815-337-2032
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician