Provider Demographics
NPI:1114478054
Name:AVILA, EDDA
Entity Type:Individual
Prefix:MRS
First Name:EDDA
Middle Name:
Last Name:AVILA
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 1:29620 SW 165TH CT
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-3211
Mailing Address - Country:US
Mailing Address - Phone:305-713-6017
Mailing Address - Fax:
Practice Address - Street 1:975 BAPTIST WAY
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-7600
Practice Address - Country:US
Practice Address - Phone:786-243-8598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-15
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9211627363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care