Provider Demographics
NPI:1366676835
Name:EDEN, BRENDA MARIE (NP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:MARIE
Last Name:EDEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 E LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-3810
Mailing Address - Country:US
Mailing Address - Phone:217-422-6100
Mailing Address - Fax:217-422-3217
Practice Address - Street 1:1800 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3810
Practice Address - Country:US
Practice Address - Phone:217-422-6100
Practice Address - Fax:217-422-3217
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006509364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01054366OtherRAILROAD
IL$$$$$$$$$001Medicaid
ILP01054366OtherRAILROAD
IL$$$$$$$$$001Medicaid