Provider Demographics
NPI:1043748544
Name:EDGEMON, DIANE (LE, CPE)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:EDGEMON
Suffix:
Gender:F
Credentials:LE, CPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 FENTON ST STE 11
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-4148
Mailing Address - Country:US
Mailing Address - Phone:925-337-3522
Mailing Address - Fax:
Practice Address - Street 1:60 FENTON ST STE 11
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-4148
Practice Address - Country:US
Practice Address - Phone:925-337-3522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-28
Last Update Date:2017-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL7180305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service