Provider Demographics
NPI:1164125530
Name:EDWARDS, CRYSTAL ALEXIS SYMONE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ALEXIS SYMONE
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 1:1142 ALYSUM AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-2344
Mailing Address - Country:US
Mailing Address - Phone:347-996-0777
Mailing Address - Fax:
Practice Address - Street 1:132 STANLEY CT STE N
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-9061
Practice Address - Country:US
Practice Address - Phone:678-835-8795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHCP011820374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide