Healthcare Provider Details

I. General information

NPI: 1477054849
Provider Name (Legal Business Name): WANDA FAYE EDWARDS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 05/05/2020
Certification Date: 05/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5666 LONGBOW DR
STONE MOUNTAIN GA
30087-5230
US

IV. Provider business mailing address

5666 LONGBOW DR
STONE MOUNTAIN GA
30087-5230
US

V. Phone/Fax

Practice location:
  • Phone: 954-305-1262
  • Fax:
Mailing address:
  • Phone: 678-235-8439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN5196378
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN090419
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: