Provider Demographics
NPI:1548414782
Name:EDGEMAN, MICHELLE BLALOCK (CNM)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BLALOCK
Last Name:EDGEMAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 BURLEYSON RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3181
Mailing Address - Country:US
Mailing Address - Phone:706-278-4640
Mailing Address - Fax:706-275-6599
Practice Address - Street 1:1105 BURLEYSON RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3181
Practice Address - Country:US
Practice Address - Phone:706-278-4640
Practice Address - Fax:706-275-6599
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN135120363LF0000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA472966726AMedicaid