Provider Demographics
NPI:1659665776
Name:EDWARDS, KRISTIN (ATP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W ROSEDALE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4852
Mailing Address - Country:US
Mailing Address - Phone:888-776-0556
Mailing Address - Fax:817-338-4450
Practice Address - Street 1:100 W ROSEDALE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4852
Practice Address - Country:US
Practice Address - Phone:888-776-0556
Practice Address - Fax:817-338-4450
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXATP12883247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281021010Medicaid