Provider Demographics
NPI:1265920474
Name:EDWARDS, JIMMY
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 NE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ANDREWS
Mailing Address - State:TX
Mailing Address - Zip Code:79714-4111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 8TH ST
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-6817
Practice Address - Country:US
Practice Address - Phone:940-761-9986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX818795163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse