Provider Demographics
NPI:1952635740
Name:EDMUND, MICHAL AIMEE (APRN)
Entity Type:Individual
Prefix:
First Name:MICHAL
Middle Name:AIMEE
Last Name:EDMUND
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 LATIMER ST
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:GA
Mailing Address - Zip Code:31539-6111
Mailing Address - Country:US
Mailing Address - Phone:912-500-9207
Mailing Address - Fax:432-200-9558
Practice Address - Street 1:5 LATIMER ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:GA
Practice Address - Zip Code:31539-6111
Practice Address - Country:US
Practice Address - Phone:912-500-9207
Practice Address - Fax:432-200-9558
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN115596363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA280064377QMedicaid
GA11DD2238857OtherCLIA
COC-RXN.0001814-C-NPOtherSTATE LICENSE
GARN115596OtherSTATE LICENSE
GA280064377IMedicaid
GARN115596OtherSTATE LICENSE