Provider Demographics
NPI:1114321155
Name:EDWARDS, PATRICIA
Entity Type:Individual
Prefix:MISS
First Name:PATRICIA
Middle Name:
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 1:217 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-5103
Mailing Address - Country:US
Mailing Address - Phone:920-492-0690
Mailing Address - Fax:
Practice Address - Street 1:217 N MADISON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-5103
Practice Address - Country:US
Practice Address - Phone:920-492-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-20
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI47-1999302Medicaid
WI47-1999302Medicare PIN