MEDICARE: WANDA EDWARDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1689211823
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WANDA EDWARDS

Provider Business Mailing Address
First Line	:	14409 ASHTON RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48223-3584
Country	:	US
Telephone Number	:	313-270-4888
Fax Number	:	313-270-4883

Provider Business Practice Location Address
First Line	:	29000 INKSTER RD STE 115
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48034-1097
Country	:	US
Telephone Number	:	313-270-4888
Fax Number	:

Authorized Official
Title or Position	:	OWNER - NURSE PRACTITIONER
Name	:	DR. WANDA EDWARDS
Credential	:	DNP, RN, PMHNP
Telephone Number	:	313-270-4888

Provider Enumeration Date	:	12/06/2019
Last Update Date	:	04/28/2021

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