1972825107 NPI number — JENNIFER NICOLE EDMUNDS ATC, CSCS

Table of content: JENNIFER NICOLE EDMUNDS ATC, CSCS (NPI 1972825107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972825107 NPI number — JENNIFER NICOLE EDMUNDS ATC, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDMUNDS
Provider First Name:
JENNIFER
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC, CSCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUTYAK
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ATC, CSCS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972825107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 PARK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02038-1709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-730-1371
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 FORGE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02038-3157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-528-2748
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2010

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: 2255A2300X , with the licence number:  1757 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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