Provider Demographics
NPI:1366007965
Name:EDWARDS, MADDIE ROSE
Entity Type:Individual
Prefix:
First Name:MADDIE
Middle Name:ROSE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 4TH AVE BLDG A
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-3515
Mailing Address - Country:US
Mailing Address - Phone:408-406-5078
Mailing Address - Fax:
Practice Address - Street 1:1611 4TH AVE BLDG A
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-3515
Practice Address - Country:US
Practice Address - Phone:408-406-5078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program