Provider Demographics
NPI:1437581568
Name:EDMISTON, ALLIE (NP)
Entity Type:Individual
Prefix:
First Name:ALLIE
Middle Name:
Last Name:EDMISTON
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 1:55 WHITCHER ST NE STE 460
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1171
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 WHITCHER ST NE STE 460
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1171
Practice Address - Country:US
Practice Address - Phone:770-427-7389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN279511363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner