Provider Demographics
NPI:1871620344
Name:FORCH, EDWINA T (NP)
Entity type:Individual
Prefix:
First Name:EDWINA
Middle Name:T
Last Name:FORCH
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:PO BOX 800778
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908-0778
Mailing Address - Country:US
Mailing Address - Phone:434-924-8344
Mailing Address - Fax:
Practice Address - Street 1:250 PANTOPS MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-8686
Practice Address - Country:US
Practice Address - Phone:434-924-8344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024063178363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P31600Medicare UPIN
VA500000815Medicare ID - Type Unspecified