Provider Demographics
NPI:1093088221
Name:EDO, MAGDALENE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:MAGDALENE
Middle Name:
Last Name:EDO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 EGRET COURT, PICKERINGTON OHIO 43147
Mailing Address - Street 2:105
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147
Mailing Address - Country:US
Mailing Address - Phone:614-783-0405
Mailing Address - Fax:614-833-0964
Practice Address - Street 1:1380 DUBLIN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1025
Practice Address - Country:US
Practice Address - Phone:614-488-7117
Practice Address - Fax:614-488-7118
Is Sole Proprietor?:No
Enumeration Date:2012-02-19
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH025488363L00000X, 363LF0000X
OHPN. 147207-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0379956Medicaid