Provider Demographics
NPI:1922411388
Name:EDET, IDONGESIT
Entity Type:Individual
Prefix:
First Name:IDONGESIT
Middle Name:
Last Name:EDET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IDONGESIT
Other - Middle Name:
Other - Last Name:JOSEPH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11630 BALINTORE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-3908
Mailing Address - Country:US
Mailing Address - Phone:813-616-0446
Mailing Address - Fax:
Practice Address - Street 1:11630 BALINTORE DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-3908
Practice Address - Country:US
Practice Address - Phone:813-616-0446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5631861163W00000X
FLRN9416423163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse