Provider Demographics
NPI:1740849462
Name:EDMONDSON, ANGELA RAE (NP)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:RAE
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:RAE
Other - Last Name:DETTMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1945 VERSAILLES ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-6900
Mailing Address - Country:US
Mailing Address - Phone:941-365-0770
Mailing Address - Fax:
Practice Address - Street 1:1945 VERSAILLES ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-6900
Practice Address - Country:US
Practice Address - Phone:941-365-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11002585363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily