Provider Demographics
NPI:1568810117
Name:EDWARDS, KATINA DENEEN (NP)
Entity Type:Individual
Prefix:
First Name:KATINA
Middle Name:DENEEN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27183 LASSO WAY
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-6685
Mailing Address - Country:US
Mailing Address - Phone:310-345-0101
Mailing Address - Fax:
Practice Address - Street 1:2372 MORSE AVE # 1090
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6234
Practice Address - Country:US
Practice Address - Phone:310-345-0101
Practice Address - Fax:949-681-3501
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA744354163W00000X
CA95025093363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1568810117Medicaid