Provider Demographics
NPI:1255397568
Name:EDISON, CAROLYN ELIZABETH (APRN,BC,)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ELIZABETH
Last Name:EDISON
Suffix:
Gender:F
Credentials:APRN,BC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-0001
Practice Address - Country:US
Practice Address - Phone:573-882-2273
Practice Address - Fax:573-884-4609
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO063452363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100415160AMedicaid
MO423315308Medicaid
MO152360061Medicare PIN
KS100415160AMedicaid
P51272Medicare UPIN