Provider Demographics
NPI:1932656311
Name:EDWARDS, KELLEY R (NP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:R
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:NP
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 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:
Practice Address - Street 1:2665 FOX POINTE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-3222
Practice Address - Country:US
Practice Address - Phone:812-378-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-02
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006506A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1125026OtherMEDICARE PTAN
IN201386320Medicaid
ININ1127025OtherMEDICARE PTAN