Healthcare Provider Details

I. General information

NPI: 1205765583
Provider Name (Legal Business Name): NIKIJHA EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 LEE LANE RD
ROANOKE RAPIDS NC
27870-8551
US

IV. Provider business mailing address

214 LEE LANE RD
ROANOKE RAPIDS NC
27870-8551
US

V. Phone/Fax

Practice location:
  • Phone: 252-578-5119
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPO21986
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: