Provider Demographics
NPI:1720086697
Name:EDWARDS, WANDA E (NP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:E
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:ELOISE - ROBINSON
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DNP, PMHCNS-BC, NP
Mailing Address - Street 1:14409 ASHTON RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-3584
Mailing Address - Country:US
Mailing Address - Phone:313-837-8756
Mailing Address - Fax:313-270-4883
Practice Address - Street 1:29000 INKSTER RD
Practice Address - Street 2:STE 115
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1097
Practice Address - Country:US
Practice Address - Phone:313-270-4888
Practice Address - Fax:313-270-4883
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704102153163WC1600X, 163WP0809X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI693558OtherVALUE OPTIONS - PROVIDER CONNECT USER ID
MIM16694OtherMEDICARE - PTAN
MI0861058OtherBCBS PIN