Basic Information
| Provider Information | |||||||||
| NPI: | 1609147883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDGMON | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIRSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439506700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406955955 | ||||||||
| FaxNumber: | 7406951503 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIRSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439506700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406955955 | ||||||||
| FaxNumber: | 7406951503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2012 | ||||||||
| LastUpdateDate: | 04/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 74438 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN.CNP.025713 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3810026383 | 05 | WV | MEDICAID | P01213515 | 01 | RAILROAD MEDICARE | OTHER | 0094092 | 05 | OH | MEDICAID |