Provider Demographics
NPI:1689461717
Name:EDWARDS, CONNIE LEE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:LEE
Last Name:EDWARDS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1346
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-1346
Mailing Address - Country:US
Mailing Address - Phone:304-752-6868
Mailing Address - Fax:304-928-2039
Practice Address - Street 1:699 STRATTON ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-4020
Practice Address - Country:US
Practice Address - Phone:304-752-6868
Practice Address - Fax:304-928-2039
Is Sole Proprietor?:No
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant