Provider Demographics
NPI:1104388958
Name:EDISON, KAITLYN NICOLE
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:NICOLE
Last Name:EDISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E CLARK STREET
Mailing Address - Street 2:FOSTER KNOX RM 205
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093
Mailing Address - Country:US
Mailing Address - Phone:314-625-1802
Mailing Address - Fax:
Practice Address - Street 1:108 W SOUTH STREET
Practice Address - Street 2:MORROW 125
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093
Practice Address - Country:US
Practice Address - Phone:660-543-4256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer