1407866635 NPI number — MRS. JENNIFER WOLF EDGSON R.N., C.C.M.

Table of content: MRS. JENNIFER WOLF EDGSON R.N., C.C.M. (NPI 1407866635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407866635 NPI number — MRS. JENNIFER WOLF EDGSON R.N., C.C.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDGSON
Provider First Name:
JENNIFER
Provider Middle Name:
WOLF
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
R.N., C.C.M.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOLF
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
LYNNE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407866635
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4432 ROBIN HOOD TRL W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34232-2637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-377-8313
Provider Business Mailing Address Fax Number:
941-377-0194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 CATTLEMEN RD
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34232-6283
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-955-5191
Provider Business Practice Location Address Fax Number:
941-341-4269
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WC0400X , with the licence number:  RN9164010 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 311749900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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