Provider Demographics
NPI:1215207246
Name:EDWARDS, KISHA R (RN, BSN)
Entity Type:Individual
Prefix:
First Name:KISHA
Middle Name:R
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 MIDDLE COUNTRY RD
Mailing Address - Street 2:STE 7132
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2580
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1070 MIDDLE COUNTRY RD
Practice Address - Street 2:STE 7132
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2580
Practice Address - Country:US
Practice Address - Phone:347-351-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-06
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300432164W00000X
NY896075163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical Nurse