Provider Demographics
NPI:1457831935
Name:EDOUARD, MARIE JESSY (RN)
Entity Type:Individual
Prefix:
First Name:MARIE JESSY
Middle Name:
Last Name:EDOUARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:JESSY
Other - Last Name:EDOUARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:UPHAM'S CORNER HEALTH CENTER
Mailing Address - Street 2:500 COLUMBIA RD
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125
Mailing Address - Country:US
Mailing Address - Phone:617-287-8000
Mailing Address - Fax:617-287-0129
Practice Address - Street 1:UPHAM'S CORNER HEALTH CENTER
Practice Address - Street 2:415 COLUMBIA RD
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125
Practice Address - Country:US
Practice Address - Phone:617-287-8000
Practice Address - Fax:617-287-0129
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN234047163WC0400X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management