=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811798622
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDYN ALYSSA EDWARDS AGNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2025
-----------------------------------------------------
Last Update Date | 07/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5959 BIG TREE RD
-----------------------------------------------------
City | ORCHARD PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14127-2291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-422-5677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4004 OCKLER AVE
-----------------------------------------------------
City | HAMBURG
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14075-4438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-880-6172
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 312203
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------