Healthcare Provider Details

I. General information

NPI: 1588574131
Provider Name (Legal Business Name): JESSICA LYNN EDWARDS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4614 OLD STATE RD
CARTHAGE NY
13619-6066
US

IV. Provider business mailing address

4614 OLD STATE RD
CARTHAGE NY
13619-6066
US

V. Phone/Fax

Practice location:
  • Phone: 315-586-3005
  • Fax:
Mailing address:
  • Phone: 315-586-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number333010-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: