Provider Demographics
NPI:1114274255
Name:EDWARDS, TIA MARIE (LPN)
Entity Type:Individual
Prefix:MISS
First Name:TIA
Middle Name:MARIE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:TIA
Other - Middle Name:MARIE
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:1 LONG WHARF DR
Mailing Address - Street 2:SUITE 321
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5991
Mailing Address - Country:US
Mailing Address - Phone:203-781-4600
Mailing Address - Fax:203-781-4624
Practice Address - Street 1:1 LONG WHARF DR
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5991
Practice Address - Country:US
Practice Address - Phone:203-781-4600
Practice Address - Fax:203-781-4624
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033043164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008003745Medicaid
CT004041000Medicaid