Healthcare Provider Details

I. General information

NPI: 1093471781
Provider Name (Legal Business Name): GWENDOLYN FAYE HURT-EDWARDS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 NEW COVINGTON PIKE STE 112
MEMPHIS TN
38128-2526
US

IV. Provider business mailing address

3000 GETWELL RD
MEMPHIS TN
38118-2205
US

V. Phone/Fax

Practice location:
  • Phone: 662-655-9375
  • Fax:
Mailing address:
  • Phone: 901-422-6000
  • Fax: 901-542-0167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number329824
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: