Provider Demographics
NPI:1477155315
Name:EDWARDS, TERESA SUE
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:SUE
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 1:1612 FLETCHER PIKE
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:OH
Mailing Address - Zip Code:45368-8718
Mailing Address - Country:US
Mailing Address - Phone:937-322-1216
Mailing Address - Fax:
Practice Address - Street 1:1612 FLETCHER PIKE
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:OH
Practice Address - Zip Code:45368-8718
Practice Address - Country:US
Practice Address - Phone:193-760-5516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2459772376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2459772Medicaid