Provider Demographics
NPI:1063536225
Name:REARDON, EDWARD LEO JR (LPN)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:LEO
Last Name:REARDON
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MCHUGH AVE
Mailing Address - Street 2:
Mailing Address - City:BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01821-5941
Mailing Address - Country:US
Mailing Address - Phone:978-667-5804
Mailing Address - Fax:
Practice Address - Street 1:17 MCHUGH AVE
Practice Address - Street 2:
Practice Address - City:BILLERICA
Practice Address - State:MA
Practice Address - Zip Code:01821-5941
Practice Address - Country:US
Practice Address - Phone:978-667-5804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA58456164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0711233OtherINDEPENDENT NURSE