Provider Demographics
NPI:1194028084
Name:JACKSONEDGE, FATIMA MARIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:FATIMA
Middle Name:MARIE
Last Name:JACKSONEDGE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WESTMINSTER AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-1714
Mailing Address - Country:US
Mailing Address - Phone:716-225-7752
Mailing Address - Fax:
Practice Address - Street 1:346 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1804
Practice Address - Country:US
Practice Address - Phone:716-856-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY540500-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse