Provider Demographics
NPI:1184977126
Name:EDL, PAMELA JEAN (LPN)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:JEAN
Last Name:EDL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 WELLS ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:WI
Mailing Address - Zip Code:53582-9650
Mailing Address - Country:US
Mailing Address - Phone:608-924-2520
Mailing Address - Fax:
Practice Address - Street 1:103 WELLS ST
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:WI
Practice Address - Zip Code:53582-9650
Practice Address - Country:US
Practice Address - Phone:608-924-2520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI314201031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse