Provider Demographics
NPI:1811947401
Name:EDGE, SUSAN (RN,FNP-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:EDGE
Suffix:
Gender:F
Credentials:RN,FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5020 COUNTY ROAD 701
Mailing Address - Street 2:
Mailing Address - City:KIRBYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75956-4912
Mailing Address - Country:US
Mailing Address - Phone:409-363-4233
Mailing Address - Fax:
Practice Address - Street 1:205 E LAVIELLE ST
Practice Address - Street 2:
Practice Address - City:KIRBYVILLE
Practice Address - State:TX
Practice Address - Zip Code:75956-2119
Practice Address - Country:US
Practice Address - Phone:409-423-2217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX249269363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174741201Medicaid
TXQ48870Medicare UPIN
TX8D7674Medicare ID - Type UnspecifiedMEDICARE