Provider Demographics
NPI:1124780267
Name:EDIE, STEPHANIE MARIE (RN, PEL-CSN)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:EDIE
Suffix:
Gender:F
Credentials:RN, PEL-CSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2916 SHEFFIELD DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1577
Mailing Address - Country:US
Mailing Address - Phone:708-846-6807
Mailing Address - Fax:
Practice Address - Street 1:601 WILLOW ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1140
Practice Address - Country:US
Practice Address - Phone:815-806-4600
Practice Address - Fax:815-806-4601
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.410123163W00000X
IL2534054163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No163W00000XNursing Service ProvidersRegistered Nurse