Provider Demographics
NPI:1861852816
Name:EDWARDS, AMYGRACE (RN)
Entity Type:Individual
Prefix:
First Name:AMYGRACE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1198
Mailing Address - Street 2:
Mailing Address - City:BAILEY
Mailing Address - State:CO
Mailing Address - Zip Code:80421-8198
Mailing Address - Country:US
Mailing Address - Phone:719-839-0757
Mailing Address - Fax:
Practice Address - Street 1:825 CLARK STREET
Practice Address - Street 2:SUITE A
Practice Address - City:FAIRPLAY
Practice Address - State:CO
Practice Address - Zip Code:80440-0846
Practice Address - Country:US
Practice Address - Phone:719-836-4154
Practice Address - Fax:719-836-3433
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1636804163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse