1073556411 NPI number — TERESA A. EDISON ARNP

Table of content: TERESA A. EDISON ARNP (NPI 1073556411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073556411 NPI number — TERESA A. EDISON ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDISON
Provider First Name:
TERESA
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GREENQUIST
Provider Other First Name:
TERESA
Provider Other Middle Name:
A.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073556411
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1824 KING STREET
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32204-4736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-388-1820
Provider Business Mailing Address Fax Number:
904-388-1827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4205 BELFORT ROAD
Provider Second Line Business Practice Location Address:
SUITE 4020
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-1475
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-450-6444
Provider Business Practice Location Address Fax Number:
904-296-9542
Provider Enumeration Date:
06/14/2006

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: 363LF0000X , with the licence number:  30317 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 1940972 , 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: 003150537A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 307506100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 019371400 . 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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