Provider Demographics
NPI:1942917810
Name:EDWARDS, KIMBERLY CARLEEN (RN DNP FNP STUDENT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:CARLEEN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:RN DNP FNP STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 NW 26TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97367-4307
Mailing Address - Country:US
Mailing Address - Phone:509-720-4953
Mailing Address - Fax:
Practice Address - Street 1:1606 NW 26TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-4307
Practice Address - Country:US
Practice Address - Phone:509-720-4953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OR200142508RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program