Provider Demographics
NPI:1609436203
Name:EDGE, SHAWNA R (APRN)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:R
Last Name:EDGE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SHAWNA
Other - Middle Name:R
Other - Last Name:TAIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:13067 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0926
Mailing Address - Country:US
Mailing Address - Phone:813-779-6303
Mailing Address - Fax:
Practice Address - Street 1:13067 N TELECOM PKWY
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0926
Practice Address - Country:US
Practice Address - Phone:813-779-6303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9380827163W00000X
FLAPRN11002861363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse