Provider Demographics
NPI:1487628392
Name:EDENFIELD, TERESSA (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:TERESSA
Middle Name:
Last Name:EDENFIELD
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MRS
Other - First Name:TERESSA
Other - Middle Name:EDENFIELD
Other - Last Name:TODD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:20370 NE BURNS AVE
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-1045
Mailing Address - Country:US
Mailing Address - Phone:850-237-3000
Mailing Address - Fax:850-237-3001
Practice Address - Street 1:20370 NE BURNS AVE
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1045
Practice Address - Country:US
Practice Address - Phone:850-237-3000
Practice Address - Fax:850-237-3001
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1738452207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL301696000Medicaid
FLS30497Medicare UPIN
FL301696000Medicaid