Provider Demographics
NPI:1275818817
Name:EDWARDS, SUSAN T (ANP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:T
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:ANP
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 249
Mailing Address - Street 2:
Mailing Address - City:YADKINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27055-0249
Mailing Address - Country:US
Mailing Address - Phone:336-679-4963
Mailing Address - Fax:336-679-2549
Practice Address - Street 1:640 PARKWOOD MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2487
Practice Address - Country:US
Practice Address - Phone:336-526-7997
Practice Address - Fax:336-526-3537
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005363363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC2838AMedicare PIN