Provider Demographics
NPI:1710448717
Name:EDEN, NICOLETTE (DO)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:EDEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 BOARDMAN CANFIELD RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9803
Mailing Address - Country:US
Mailing Address - Phone:330-532-7215
Mailing Address - Fax:
Practice Address - Street 1:4135 BOARDMAN CANFIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-9803
Practice Address - Country:US
Practice Address - Phone:330-532-7215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-31
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.016125207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology