=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023993227
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESILIENT CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2025
-----------------------------------------------------
Last Update Date | 08/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4425 LAFAYETTE ST
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32446-3312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-600-6430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4425 LAFAYETTE ST
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32446-3312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-600-6430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JERRI EDWARDS
-----------------------------------------------------
Credential | DNP, APRN
-----------------------------------------------------
Telephone | 850-600-6430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------