Provider Demographics
NPI:1134871999
Name:EDMONDS, MAGGIE LEAN
Entity type:Individual
Prefix:
First Name:MAGGIE
Middle Name:LEAN
Last Name:EDMONDS
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 1:5324 CHEVAL PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-4938
Mailing Address - Country:US
Mailing Address - Phone:704-301-1568
Mailing Address - Fax:
Practice Address - Street 1:5324 CHEVAL PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-4938
Practice Address - Country:US
Practice Address - Phone:704-301-1568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver