Provider Demographics
NPI:1467158402
Name:EDWARDS, CAITLYN JO
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:JO
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 1:16600 BIRKDALE COMMONS PKWY STE E
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-6181
Mailing Address - Country:US
Mailing Address - Phone:704-896-8680
Mailing Address - Fax:
Practice Address - Street 1:7028 GOLDEN EAGLE TRL
Practice Address - Street 2:
Practice Address - City:IRON STATION
Practice Address - State:NC
Practice Address - Zip Code:28080-5720
Practice Address - Country:US
Practice Address - Phone:704-999-0792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01001308363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant