Provider Demographics
NPI:1245210285
Name:EDIE, JEANETTE MARIE (CNS APRN CWOCN CFC)
Entity Type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:MARIE
Last Name:EDIE
Suffix:
Gender:F
Credentials:CNS APRN CWOCN CFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5979 SOUTHDOWN LN
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8375
Mailing Address - Country:US
Mailing Address - Phone:815-871-4747
Mailing Address - Fax:
Practice Address - Street 1:5979 SOUTHDOWN LN
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-8375
Practice Address - Country:US
Practice Address - Phone:815-871-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003232364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP44556Medicare UPIN
ILL89222Medicare ID - Type Unspecified