Provider Demographics
NPI:1477054849
Name:EDWARDS, WANDA FAYE (LPN)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:FAYE
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 1:5666 LONGBOW DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-5230
Mailing Address - Country:US
Mailing Address - Phone:678-235-8439
Mailing Address - Fax:
Practice Address - Street 1:5666 LONGBOW DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-5230
Practice Address - Country:US
Practice Address - Phone:954-305-1262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5196378164W00000X
247000000X, 251J00000X, 385H00000X
GALPN090419164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health InformationGroup - Multi-Specialty
No251J00000XAgenciesNursing CareGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care