Provider Demographics
NPI:1508594532
Name:KWINKE, EDITH
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:KWINKE
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 1:260 WINDSOR WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-6497
Mailing Address - Country:US
Mailing Address - Phone:404-200-1682
Mailing Address - Fax:
Practice Address - Street 1:260 WINDSOR WAY
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-6497
Practice Address - Country:US
Practice Address - Phone:404-200-1682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA310004163WH0200X, 163WP0809X
FL9585284163WH0200X
GA5977227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
No227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA05252005Medicaid