Provider Demographics
NPI:1184493116
Name:EDWARDS, SHAUWANNA NICOLE
Entity type:Individual
Prefix:
First Name:SHAUWANNA
Middle Name:NICOLE
Last Name:EDWARDS
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 1:504 BRICK KITCHEN RD
Mailing Address - Street 2:
Mailing Address - City:HOOKERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28538-7010
Mailing Address - Country:US
Mailing Address - Phone:252-525-3997
Mailing Address - Fax:
Practice Address - Street 1:504 BRICK KITCHEN RD
Practice Address - Street 2:
Practice Address - City:HOOKERTON
Practice Address - State:NC
Practice Address - Zip Code:28538-7010
Practice Address - Country:US
Practice Address - Phone:252-525-3997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 3104A0625X, 311ZA0620X, 320600000X, 320900000X, 322D00000X, 323P00000X, 385HR2060X, 385HR2065X, 320700000X
NC320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child