Healthcare Provider Details

I. General information

NPI: 1982811337
Provider Name (Legal Business Name): KELLY EDWARDS LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 PHILPOT LANE
BEAVER WV
25813
US

IV. Provider business mailing address

885 DEER MOUNTAIN DR
PRINCETON WV
24740-7690
US

V. Phone/Fax

Practice location:
  • Phone: 304-254-9262
  • Fax:
Mailing address:
  • Phone: 304-487-8754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number18155
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: