Provider Demographics
NPI:1093128860
Name:VON MAACK, EDELWEISS (NP-C)
Entity Type:Individual
Prefix:
First Name:EDELWEISS
Middle Name:
Last Name:VON MAACK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:EDELWEISS
Other - Middle Name:
Other - Last Name:WHITSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:24785 STEWART ST.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-558-4594
Mailing Address - Fax:909-558-0433
Practice Address - Street 1:24785 STEWART ST STE 111
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1721
Practice Address - Country:US
Practice Address - Phone:909-558-4594
Practice Address - Fax:909-558-0433
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60451797363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology