MEDICARE: WANDA E EDWARDS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC1600X	Continuing Education/Staff Development Registered Nurse	4704102153	MI
2	163WP0809X	Adult Psychiatric/Mental Health Registered Nurse	4704102153	MI
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	4704102153	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	M16694	OTHER	MI	MEDICARE - PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	693558	OTHER	MI	VALUE OPTIONS - PROVIDER CONNECT USER ID
3	0861058	OTHER	MI	BCBS PIN

General Provider Information

NPI Number	:	1720086697
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA E EDWARDS NP

Provider Business Mailing Address
First Line	:	14409 ASHTON RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48223-3584
Country	:	US
Telephone Number	:	313-837-8756
Fax Number	:	313-270-4883

Provider Business Practice Location Address
First Line	:	29000 INKSTER RD
Second Line	:	STE 115
City	:	SOUTHFIELD
State	:	MI
Zip	:	48034-1097
Country	:	US
Telephone Number	:	313-270-4888
Fax Number	:	313-270-4883

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	12/01/2020

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