Provider Demographics
NPI:1598945826
Name:EDWARDS, SUSAN M (CA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 SINGLETARY PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-0954
Mailing Address - Country:US
Mailing Address - Phone:910-574-8113
Mailing Address - Fax:
Practice Address - Street 1:CLARK HEALTH CLINIC
Practice Address - Street 2:BLDG 5-4257 BASTOGNE EXT.
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-2575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-03
Last Update Date:2007-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCERTIFICATE111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Single Specialty