Provider Demographics
NPI:1063167658
Name:EDMONDS, CHRISTIAN JERRARD
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:JERRARD
Last Name:EDMONDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11721 MANGO GROVES BLVD
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-6405
Mailing Address - Country:US
Mailing Address - Phone:813-500-8919
Mailing Address - Fax:
Practice Address - Street 1:11721 MANGO GROVES BLVD
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-6405
Practice Address - Country:US
Practice Address - Phone:813-500-8919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-13
Last Update Date:2022-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL112858700261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities