Provider Demographics
NPI:1013458561
Name:EDMOND, WENDY PHREUD (AC-AGNP)
Entity type:Individual
Prefix:MR
First Name:WENDY
Middle Name:PHREUD
Last Name:EDMOND
Suffix:
Gender:M
Credentials:AC-AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3178 STIRLING RD UNIT J7
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2058
Mailing Address - Country:US
Mailing Address - Phone:786-290-3485
Mailing Address - Fax:
Practice Address - Street 1:9299 SW 152ND ST STE 203
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1776
Practice Address - Country:US
Practice Address - Phone:305-322-4166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM64577363LA2100X
FLAPRN9336037363LA2100X
ID73900363LA2100X
IN71013924A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300076966Medicaid
FL023103400Medicaid
IN267030310OtherMEDICARE PTAN
FLOD206OtherMEDICARE HF