Healthcare Provider Details

I. General information

NPI: 1013753243
Provider Name (Legal Business Name): CHRISTINA JOCKLENE EDWARDS AGPCNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 S LAKE DR PO BOX 84432
LEXINGTON SC
29073-9760
US

IV. Provider business mailing address

1830 S LAKE DR PO BOX 84432
LEXINGTON SC
29073-9760
US

V. Phone/Fax

Practice location:
  • Phone: 803-477-4745
  • Fax: 843-258-4600
Mailing address:
  • Phone: 803-477-4745
  • Fax: 843-258-4600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number28779
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28779
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number28779RX
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number28779RX
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: