Provider Demographics
NPI:1699520932
Name:DE SOTO, EDITH KARINA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:KARINA
Last Name:DE SOTO
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 HARRISON AVE UNIT 7343
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61126-2405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 S 44TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-2809
Practice Address - Country:US
Practice Address - Phone:402-807-5117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE115516363LP0808X
IL209.029566363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health