Healthcare Provider Details

I. General information

NPI: 1063620722
Provider Name (Legal Business Name): CONNIE EDELEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4266 SUNBEAM RD
JACKSONVILLE FL
32257-2425
US

IV. Provider business mailing address

4266 SUNBEAM RD
JACKSONVILLE FL
32257-2425
US

V. Phone/Fax

Practice location:
  • Phone: 904-407-7700
  • Fax: 904-407-6001
Mailing address:
  • Phone: 904-407-7700
  • Fax: 904-407-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number2010-00028
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116018187
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberME134775
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: