Provider Demographics
NPI:1700259595
Name:EDWARDS, KELLY DEVOTA
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DEVOTA
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 1:144 COUNTY ROAD 3452
Mailing Address - Street 2:
Mailing Address - City:HALEYVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35565-7257
Mailing Address - Country:US
Mailing Address - Phone:205-269-8654
Mailing Address - Fax:
Practice Address - Street 1:100 NORTH WASHINGTON ST STATION 14
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:AL
Practice Address - Zip Code:35470
Practice Address - Country:US
Practice Address - Phone:205-652-3452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program