Healthcare Provider Details

I. General information

NPI: 1457841249
Provider Name (Legal Business Name): DESTANY EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8706 S US HIGHWAY 25
CORBIN KY
40701-4974
US

IV. Provider business mailing address

432 BOULDER DR
LONDON KY
40741-8809
US

V. Phone/Fax

Practice location:
  • Phone: 606-677-1166
  • Fax:
Mailing address:
  • Phone: 606-260-7646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number251043
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: