Provider Demographics
NPI:1295242204
Name:EDGE, JANET GAIL
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:GAIL
Last Name:EDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 OAKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-4538
Mailing Address - Country:US
Mailing Address - Phone:407-376-0474
Mailing Address - Fax:
Practice Address - Street 1:424 N 8TH ST
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-4110
Practice Address - Country:US
Practice Address - Phone:863-419-5065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010294900Medicaid