Provider Demographics
NPI:1265159024
Name:EDMUNDSON, STACI (RN)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:EDMUNDSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:EATON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:161 MORTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-5616
Mailing Address - Country:US
Mailing Address - Phone:407-756-5067
Mailing Address - Fax:
Practice Address - Street 1:161 MORTON BLVD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-5616
Practice Address - Country:US
Practice Address - Phone:407-756-5067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY673226-01163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool