Provider Demographics
NPI:1235306853
Name:EDWARDS, BESSIE DENIESE (EDS)
Entity Type:Individual
Prefix:MS
First Name:BESSIE
Middle Name:DENIESE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 505
Mailing Address - Street 2:17434 NE 18TH AVENUE
Mailing Address - City:CITRA
Mailing Address - State:FL
Mailing Address - Zip Code:32113-0505
Mailing Address - Country:US
Mailing Address - Phone:352-595-2542
Mailing Address - Fax:
Practice Address - Street 1:17434 NE 18TH AVE
Practice Address - Street 2:
Practice Address - City:CITRA
Practice Address - State:FL
Practice Address - Zip Code:32113-0505
Practice Address - Country:US
Practice Address - Phone:352-595-2542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL763190100Medicaid