Provider Demographics
NPI:1891822367
Name:EDWARDS, PHYLLIS ANNETTE
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:ANNETTE
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:PO BOX 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:7 DEYE LN
Practice Address - Street 2:
Practice Address - City:EASTSOUND
Practice Address - State:WA
Practice Address - Zip Code:98245-8578
Practice Address - Country:US
Practice Address - Phone:360-376-2561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00026106104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8384117Medicaid
WAG8854532Medicare PIN