Provider Demographics
NPI:1790301141
Name:EDWARDS, TANISHA
Entity Type:Individual
Prefix:MRS
First Name:TANISHA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5943 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-0444
Mailing Address - Country:US
Mailing Address - Phone:817-404-7733
Mailing Address - Fax:
Practice Address - Street 1:5943 RIDGEWAY DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-0444
Practice Address - Country:US
Practice Address - Phone:817-404-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171M00000X
372600000X, 373H00000X, 3747A0650X, 3747P1801X, 372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No372600000XNursing Service Related ProvidersAdult Companion
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant