Healthcare Provider Details

I. General information

NPI: 1306562764
Provider Name (Legal Business Name): JONATHAN RALPH EDGETTE FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 KENSINGTON AVE
FLINT MI
48503-2044
US

IV. Provider business mailing address

302 KENSINGTON AVE
FLINT MI
48503-2044
US

V. Phone/Fax

Practice location:
  • Phone: 810-762-8400
  • Fax: 810-762-8118
Mailing address:
  • Phone: 810-762-8400
  • Fax: 810-762-8118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704253991
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: