Provider Demographics
NPI:1841753027
Name:EDWARDS, ELLISON AMY
Entity Type:Individual
Prefix:
First Name:ELLISON
Middle Name:AMY
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 1:262 E FRANCES LN
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-1975
Mailing Address - Country:US
Mailing Address - Phone:480-278-6954
Mailing Address - Fax:
Practice Address - Street 1:262 E FRANCES LN
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1975
Practice Address - Country:US
Practice Address - Phone:480-278-6954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-13
Last Update Date:2019-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ220547363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ220547OtherCASH PAY- MEDICAL SPA AND BASIC DERMATOLOGY