Healthcare Provider Details

I. General information

NPI: 1508525965
Provider Name (Legal Business Name): STEPHANIE YOLANDA EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 12/14/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 RACE ST, ROLLING FORK, MS 39159
ROLLING FORK MS
39159
US

IV. Provider business mailing address

302 STARLITE DR
YAZOO CITY MS
39194
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-0477
  • Fax:
Mailing address:
  • Phone: 662-571-3171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number905048
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: