Provider Demographics
NPI:1396364741
Name:EDMISTON, ELIZABETH (PHD, RN)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:EDMISTON
Suffix:
Gender:F
Credentials:PHD, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 MALLARD DR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-3031
Mailing Address - Country:US
Mailing Address - Phone:419-565-8579
Mailing Address - Fax:
Practice Address - Street 1:1612 MALLARD DR
Practice Address - Street 2:
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-3031
Practice Address - Country:US
Practice Address - Phone:419-565-8579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.360267163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice