Healthcare Provider Details

I. General information

NPI: 1881573798
Provider Name (Legal Business Name): ILLIYAH PHYLLIS EDWARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 E KING HENRY DR
FLORENCE SC
29506-8621
US

IV. Provider business mailing address

3700 E KING HENRY DR
FLORENCE SC
29506-8621
US

V. Phone/Fax

Practice location:
  • Phone: 917-815-6395
  • Fax:
Mailing address:
  • Phone: 917-815-6395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number30844
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: