Provider Demographics
NPI:1639378987
Name:EDWARDS, NICOLE YVONNE (DO)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:YVONNE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7001 SAINT ANDREWS RD STE 428
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-1137
Mailing Address - Country:US
Mailing Address - Phone:803-543-2913
Mailing Address - Fax:803-708-4365
Practice Address - Street 1:1313 SAINT ANDREWS RD STE 3
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210
Practice Address - Country:US
Practice Address - Phone:803-543-2913
Practice Address - Fax:803-708-4365
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC010909Medicaid
SCAA49947682Medicare PIN