Provider Demographics
NPI:1235279795
Name:EDWARDS, BETHANY ROXANNA (MSN, BC, FNP)
Entity Type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:ROXANNA
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MSN, BC, FNP
Other - Prefix:MS
Other - First Name:BETH
Other - Middle Name:R
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSN, BC, FNP
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:7055 GLEN OAKS DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70812-1832
Practice Address - Country:US
Practice Address - Phone:225-355-7284
Practice Address - Fax:225-356-1616
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006091363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1682349Medicaid