Provider Demographics
NPI:1104388958
Name:EDISON, KAITLYN NICOLE
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:NICOLE
Last Name:EDISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10717 SAINT BERNARD LN
Mailing Address - Street 2:
Mailing Address - City:SAINT ANN
Mailing Address - State:MO
Mailing Address - Zip Code:63074-2519
Mailing Address - Country:US
Mailing Address - Phone:314-625-1802
Mailing Address - Fax:
Practice Address - Street 1:2549 HACKMANN RD
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-5452
Practice Address - Country:US
Practice Address - Phone:636-851-5094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960052992255A2300X
MO20200355282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer