=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639785546
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL EDGE NURSING, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2020
-----------------------------------------------------
Last Update Date | 09/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 MARY LANE
-----------------------------------------------------
City | ANNISTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-499-4354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 MARY LANE
-----------------------------------------------------
City | ANNISTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-499-4354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | BRENDA KAY VANNATTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 815-499-4354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171000000X
-----------------------------------------------------
Taxonomy Name | Military Health Care Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------