Provider Demographics
NPI:1750893889
Name:EDWARDS, KENT (FNP-C)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11488 SUGAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-4315
Mailing Address - Country:US
Mailing Address - Phone:618-927-1610
Mailing Address - Fax:
Practice Address - Street 1:11488 SUGAR CREEK RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:IL
Practice Address - Zip Code:62812-4315
Practice Address - Country:US
Practice Address - Phone:618-927-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016765363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner