Healthcare Provider Details

I. General information

NPI: 1912199753
Provider Name (Legal Business Name): JOHNNA MARIE EDMUNDS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 BAYWOOD DR
PETALUMA CA
94954-5501
US

IV. Provider business mailing address

3435 SONOMA MOUNTAIN RD
PETALUMA CA
94954-9201
US

V. Phone/Fax

Practice location:
  • Phone: 707-765-2425
  • Fax:
Mailing address:
  • Phone: 707-664-2041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number204315
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: