Provider Demographics
NPI:1740680487
Name:EDGE, NICOLE PAMELA (BCBA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:PAMELA
Last Name:EDGE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:PAMELA
Other - Last Name:SCHIEGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12501 WORLD PLAZA LN BLDG 51
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3991
Mailing Address - Country:US
Mailing Address - Phone:239-349-3139
Mailing Address - Fax:239-984-4372
Practice Address - Street 1:12501 WORLD PLAZA LN BLDG 51
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3991
Practice Address - Country:US
Practice Address - Phone:239-349-3139
Practice Address - Fax:239-984-4372
Is Sole Proprietor?:No
Enumeration Date:2014-08-31
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-17-26204103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017567700Medicaid