=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952896706
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAVEN SIMONE EDWARDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2018
-----------------------------------------------------
Last Update Date | 08/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3451 GOODMAN RD E STE 108
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-890-6953
-----------------------------------------------------
Fax | 662-890-6954
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 CRESCENT CENTRE DR STE 600
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37067-7286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-373-1350
-----------------------------------------------------
Fax | 615-221-9054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT6541
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------