Provider Demographics
NPI:1821863523
Name:EDMOND, EVELYN ADDIE
Entity Type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:ADDIE
Last Name:EDMOND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 DIXIE HWY
Mailing Address - Street 2:STATE OF ILLINOIS DEPT. OF HUMAN SERVICES
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 DIXIE HWY
Practice Address - Street 2:STATE OF ILLINOIS DEPT. OF HUMAN SERVICES
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411
Practice Address - Country:US
Practice Address - Phone:708-709-3316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-212533163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse