Healthcare Provider Details

I. General information

NPI: 1285398156
Provider Name (Legal Business Name): TAJUANA CHANTELL EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 02/09/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 JOHN DANTIS RD SW
ALBUQUERQUE NM
87151-0100
US

IV. Provider business mailing address

700 8TH AVE W STE 101
PALMETTO FL
34221-4737
US

V. Phone/Fax

Practice location:
  • Phone: 505-417-1416
  • Fax:
Mailing address:
  • Phone: 941-776-4000
  • Fax: 941-845-4963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number72615
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61363319
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11016252
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: