Provider Demographics
NPI:1780170571
Name:IDEHEN, EDNA OBEHI (NP)
Entity type:Individual
Prefix:MRS
First Name:EDNA
Middle Name:OBEHI
Last Name:IDEHEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:EDNA
Other - Middle Name:OBEHI
Other - Last Name:IDEHEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:101 CABARRUS AVE E
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-3699
Mailing Address - Country:US
Mailing Address - Phone:888-849-7379
Mailing Address - Fax:855-857-7333
Practice Address - Street 1:101 CABARRUS AVE E
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-3699
Practice Address - Country:US
Practice Address - Phone:888-849-7379
Practice Address - Fax:855-857-7333
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5010620363LF0000X
SC21790363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health