Healthcare Provider Details

I. General information

NPI: 1174148340
Provider Name (Legal Business Name): SANDRA EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 FREDERICA ST STE 204
OWENSBORO KY
42301-3077
US

IV. Provider business mailing address

PO BOX 22619
OWENSBORO KY
42303
US

V. Phone/Fax

Practice location:
  • Phone: 270-574-5600
  • Fax: 270-574-5609
Mailing address:
  • Phone: 270-574-5600
  • Fax: 270-574-5609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71010785A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3014693
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: