Provider Demographics
NPI:1588358436
Name:EDMOND, DALISHA (FNP)
Entity type:Individual
Prefix:
First Name:DALISHA
Middle Name:
Last Name:EDMOND
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5833 W FOREST VIEW CT UNIT C
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-5503
Mailing Address - Country:US
Mailing Address - Phone:414-949-3583
Mailing Address - Fax:
Practice Address - Street 1:3365 S 103RD ST STE 210
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-4161
Practice Address - Country:US
Practice Address - Phone:262-814-7080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIF04230167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1588358436Medicaid