Provider Demographics
NPI:1891995205
Name:MEDLEY, EDITH DIANE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:DIANE
Last Name:MEDLEY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:MEDLEY
Other - Middle Name:MEDICAL
Other - Last Name:LEGAL CONSULTANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NURSE LEGAL CONSULTA
Mailing Address - Street 1:5103 TANGLEWOOD CT
Mailing Address - Street 2:NA
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-2637
Mailing Address - Country:US
Mailing Address - Phone:757-638-1320
Mailing Address - Fax:757-638-1039
Practice Address - Street 1:5103 TANGLEWOOD CT
Practice Address - Street 2:NA
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2637
Practice Address - Country:US
Practice Address - Phone:757-638-1320
Practice Address - Fax:757-638-1039
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024093905363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0001093905OtherREGISTERED NURSE
VA0024093905OtherNURSE PRACTITIONER
VA0017000287OtherAUTHORIZATION TO PRESCRI
VA0017000287OtherAUTHORIZATION TO PRESCRI