Provider Demographics
NPI:1376262618
Name:EDSON, AUTUMN RASCHEL
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:RASCHEL
Last Name:EDSON
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 1:21 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:SINCLAIRVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14782-9722
Mailing Address - Country:US
Mailing Address - Phone:716-338-2413
Mailing Address - Fax:
Practice Address - Street 1:21 EAST AVE
Practice Address - Street 2:
Practice Address - City:SINCLAIRVILLE
Practice Address - State:NY
Practice Address - Zip Code:14782-9722
Practice Address - Country:US
Practice Address - Phone:716-338-2413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344868164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse