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General NPI Number Information
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NPI Number | 1760787030
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Entity Type | Individual
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Provider Name | MARY EDEM NP
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Gender | Female
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Dates
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Enumeration Date | 01/18/2011
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Last Update Date | 09/23/2016
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Provider Practice Location Address
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Address Line | 190 E HIGHLAND AVE
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City | SAN BERNARDINO
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State | CA
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Zip | 92404-3658
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Country | US
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Telephone | 909-882-4788
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Fax | 877-860-7268
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Provider Business Mailing Address
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Address Line | 200 OCEANGATE SUITE 100
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City | LONG BEACH
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State | CA
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Zip | 90802-4317
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Country | US
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Telephone | 562-499-6191
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Fax | 562-499-6171
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 20107
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License Number State | CA
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