Provider Demographics
NPI:1417410226
Name:EDMOND, ELYSEE
Entity type:Individual
Prefix:
First Name:ELYSEE
Middle Name:
Last Name:EDMOND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6836 MOORHEN CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-6073
Mailing Address - Country:US
Mailing Address - Phone:407-925-6581
Mailing Address - Fax:
Practice Address - Street 1:6836 MOORHEN CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-6073
Practice Address - Country:US
Practice Address - Phone:407-925-6581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1597363A00000X
AZ10352363A00000X
FLTPPA535363A00000X
101YM0800X
FLRN9629527163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse