Provider Demographics
NPI:1962844555
Name:KING, EDNA LEE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:EDNA
Middle Name:LEE
Last Name:KING
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N MOUNTAIN AVE
Mailing Address - Street 2:SUITE 241
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-5176
Mailing Address - Country:US
Mailing Address - Phone:909-946-0707
Mailing Address - Fax:909-946-1946
Practice Address - Street 1:400 N MOUNTAIN AVE
Practice Address - Street 2:SUITE 241
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5176
Practice Address - Country:US
Practice Address - Phone:909-946-0707
Practice Address - Fax:909-946-1946
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21541363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health