Provider Demographics
NPI:1073101499
Name:EDWARDS, BETTY ANN
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:ANN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 BELMONT BAY DR UNIT 310
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-5452
Mailing Address - Country:US
Mailing Address - Phone:703-489-7041
Mailing Address - Fax:
Practice Address - Street 1:300 SKILLMAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-1607
Practice Address - Country:US
Practice Address - Phone:347-377-5913
Practice Address - Fax:718-599-2840
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-03
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
NYF404686-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty