Healthcare Provider Details

I. General information

NPI: 1538582473
Provider Name (Legal Business Name): EDWARD LESTER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NAVARRE PL STE 5500
SOUTH BEND IN
46601-1172
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-5200
  • Fax: 574-647-5210
Mailing address:
  • Phone: 574-647-3725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71004776
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: