=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366676835
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDA MARIE EDEN NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2009
-----------------------------------------------------
Last Update Date | 03/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 E LAKE SHORE DR
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62521-3810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-422-6100
-----------------------------------------------------
Fax | 217-422-3217
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 E LAKE SHORE DR
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62521-3810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-422-6100
-----------------------------------------------------
Fax | 217-422-3217
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364S00000X
-----------------------------------------------------
Taxonomy Name | Clinical Nurse Specialist
-----------------------------------------------------
License Number | 209006509
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------