Basic Information
| Provider Information | |||||||||
| NPI: | 1447721105 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDSON | ||||||||
| FirstName: | DANIELA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | AGACNP, NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
| FaxNumber: | 5742376069 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 MEMORIAL DR STE 502 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746475875 | ||||||||
| FaxNumber: | 5746475878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2018 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 71008852A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | 71008852A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 300024411 | 05 | IN | MEDICAID |