Provider Demographics
NPI:1558830851
Name:EDSALL, COURTNEY D (APRN)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:D
Last Name:EDSALL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 NE CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1901
Mailing Address - Country:US
Mailing Address - Phone:309-672-4670
Mailing Address - Fax:
Practice Address - Street 1:112 NE CRESCENT AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1901
Practice Address - Country:US
Practice Address - Phone:309-672-4670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018452363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily