Healthcare Provider Details

I. General information

NPI: 1033692017
Provider Name (Legal Business Name): LAURA DENISS EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 CHAMBLEE TUCKER RD
CHAMBLEE GA
30341-3526
US

IV. Provider business mailing address

105 MAGNOLIA CT APT B
LEESBURG GA
31763-2300
US

V. Phone/Fax

Practice location:
  • Phone: 770-695-0049
  • Fax:
Mailing address:
  • Phone: 229-938-1208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN214601
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: