Provider Demographics
NPI:1033606371
Name:EDWARDS, KHADIJAH NICOLE (COTA)
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:NICOLE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 E MELROSE CIR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1951
Mailing Address - Country:US
Mailing Address - Phone:954-599-8961
Mailing Address - Fax:
Practice Address - Street 1:631 E MELROSE CIR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1951
Practice Address - Country:US
Practice Address - Phone:954-599-8961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty