Provider Demographics
NPI:1437403730
Name:ANDERSON, EDGAR LEOPOLD (RN)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:LEOPOLD
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1690 DUNLAWTON AVE
Mailing Address - Street 2:SUITE 125
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-8979
Mailing Address - Country:US
Mailing Address - Phone:386-246-3661
Mailing Address - Fax:386-246-3661
Practice Address - Street 1:1690 DUNLAWTON AVE STE 125
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-8980
Practice Address - Country:US
Practice Address - Phone:386-793-5743
Practice Address - Fax:386-246-3661
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2012-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN 9229694163W00000X, 163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)