Provider Demographics
NPI:1093183675
Name:EDWARD, PAULA
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:EDWARD
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 1:2205 MARGATE CT
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-8689
Mailing Address - Country:US
Mailing Address - Phone:502-489-4870
Mailing Address - Fax:
Practice Address - Street 1:2205 MARGATE CT
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-8689
Practice Address - Country:US
Practice Address - Phone:502-489-4870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-12
Last Update Date:2015-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY27455171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator