Provider Demographics
NPI:1972157410
Name:EDWARDS, DEONDRA (NP)
Entity Type:Individual
Prefix:
First Name:DEONDRA
Middle Name:
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 1:3132 SHADOW GREEN LANE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:TN
Mailing Address - Zip Code:38002
Mailing Address - Country:US
Mailing Address - Phone:731-612-4223
Mailing Address - Fax:
Practice Address - Street 1:1618 HIGHWAY 51, SUITES A&B
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019
Practice Address - Country:US
Practice Address - Phone:901-313-9274
Practice Address - Fax:901-313-9275
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26276363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily