1013458561 NPI number — MR. WENDY PHREUD EDMOND AC-AGNP

Table of content: MR. WENDY PHREUD EDMOND AC-AGNP (NPI 1013458561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013458561 NPI number — MR. WENDY PHREUD EDMOND AC-AGNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDMOND
Provider First Name:
WENDY
Provider Middle Name:
PHREUD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
AC-AGNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013458561
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3178 STIRLING RD UNIT J7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33021-2058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-290-3485
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9299 SW 152ND ST STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALMETTO BAY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33157-1776
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-322-4166
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/16/2017

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: 363LA2100X , with the licence number:  64577 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: APRN9336037 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LA2100X , with the licence number: 73900 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , with the licence number: 71013924A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 300076966 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 023103400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 267030310 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: OD206 . This is a "MEDICARE HF" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 023103400 . 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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