Provider Demographics
NPI:1265804488
Name:EDMONDS, MORGAN NICOLE (AGPCNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MORGAN
Middle Name:NICOLE
Last Name:EDMONDS
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:MS
Other - First Name:MORGAN
Other - Middle Name:NICOLE
Other - Last Name:PROUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:112 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1923
Practice Address - Country:US
Practice Address - Phone:888-403-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2016-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704293688163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse