Provider Demographics
NPI:1932935202
Name:ETIENNE, EDELINE (NP)
Entity type:Individual
Prefix:
First Name:EDELINE
Middle Name:
Last Name:ETIENNE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-3257
Mailing Address - Country:US
Mailing Address - Phone:561-523-6963
Mailing Address - Fax:
Practice Address - Street 1:7046 PENINSULA LAKE CT
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-7966
Practice Address - Country:US
Practice Address - Phone:561-523-6963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY354778207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine