Provider Demographics
NPI:1760787030
Name:EDEM, MARY (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:EDEM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:190 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3658
Practice Address - Country:US
Practice Address - Phone:909-882-4788
Practice Address - Fax:877-860-7268
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20107363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA205848-CA109020Medicare PIN
CACA205847-GA222AMedicare PIN