Provider Demographics
NPI:1417388422
Name:EDWARDS, PRINCESS YENNEJ (LPN)
Entity Type:Individual
Prefix:
First Name:PRINCESS
Middle Name:YENNEJ
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 E 94TH ST
Mailing Address - Street 2:BASEMENT APARTMENT
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-1105
Mailing Address - Country:US
Mailing Address - Phone:347-251-6292
Mailing Address - Fax:
Practice Address - Street 1:1809 NOSTRAND AVE
Practice Address - Street 2:2R
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-7181
Practice Address - Country:US
Practice Address - Phone:718-421-4884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311799164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02386459Medicaid