=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326009291
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUANA I EDMUNDS M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2006
-----------------------------------------------------
Last Update Date | 04/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3811 BROADWAY 3RD FLOOR
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11103-4045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-726-5953
-----------------------------------------------------
Fax | 718-204-5308
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 E 54TH ST # 29 A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10022-4707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-319-8069
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 133090
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | 133090
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------