Provider Demographics
NPI:1073556411
Name:EDISON, TERESA A (ARNP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:A
Last Name:EDISON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:A
Other - Last Name:GREENQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1824 KING STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4736
Mailing Address - Country:US
Mailing Address - Phone:904-388-1820
Mailing Address - Fax:904-388-1827
Practice Address - Street 1:4205 BELFORT ROAD
Practice Address - Street 2:SUITE 4020
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1475
Practice Address - Country:US
Practice Address - Phone:904-450-6444
Practice Address - Fax:904-296-9542
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1940972363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003150537AMedicaid
FL307506100Medicaid
GA003150537AMedicaid
FL307506100Medicaid
FLU7364Medicare ID - Type UnspecifiedMEDICARE NUMBER