Provider Demographics
NPI:1598367930
Name:EDWARDS, KENTRELL LAMAR
Entity Type:Individual
Prefix:
First Name:KENTRELL
Middle Name:LAMAR
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-4116
Mailing Address - Country:US
Mailing Address - Phone:561-236-0021
Mailing Address - Fax:
Practice Address - Street 1:1131 W 26TH ST
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-4116
Practice Address - Country:US
Practice Address - Phone:561-236-0021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107428100Medicaid