Healthcare Provider Details

I. General information

NPI: 1255001244
Provider Name (Legal Business Name): GRACE EDMUNDS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1311
US

IV. Provider business mailing address

4605 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1311
US

V. Phone/Fax

Practice location:
  • Phone: 304-974-5000
  • Fax:
Mailing address:
  • Phone: 304-974-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2878
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: