Provider Demographics
NPI:1235347121
Name:WADE, EDITH (LD)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 BOULEVARD ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MS
Mailing Address - Zip Code:39095-3530
Mailing Address - Country:US
Mailing Address - Phone:601-260-1254
Mailing Address - Fax:
Practice Address - Street 1:17280 HIGHWAY 17 SOUTH
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MS
Practice Address - Zip Code:39095-0479
Practice Address - Country:US
Practice Address - Phone:662-834-1857
Practice Address - Fax:662-834-1859
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS726330133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSD0482OtherLICENSED DIETICTIAN
MS03300362Medicaid