Healthcare Provider Details

I. General information

NPI: 1720086697
Provider Name (Legal Business Name): WANDA E EDWARDS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: WANDA ELOISE - ROBINSON EDWARDS DNP, PMHCNS-BC, NP

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29000 INKSTER RD STE 115
SOUTHFIELD MI
48034-1097
US

IV. Provider business mailing address

14409 ASHTON RD
DETROIT MI
48223-3584
US

V. Phone/Fax

Practice location:
  • Phone: 313-270-4888
  • Fax: 313-270-4883
Mailing address:
  • Phone: 313-837-8756
  • Fax: 313-270-4883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number4704102153
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number4704102153
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704102153
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: