Provider Demographics
NPI:1831529080
Name:EDWARDS, VANZANELL (ADMINISTOR)
Entity type:Individual
Prefix:
First Name:VANZANELL
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:ADMINISTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7801 MARLBOROUGH DR W
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76134-4309
Mailing Address - Country:US
Mailing Address - Phone:817-568-1445
Mailing Address - Fax:817-782-9304
Practice Address - Street 1:7801 MARLBOROUGH DR W
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76134-4309
Practice Address - Country:US
Practice Address - Phone:817-568-1445
Practice Address - Fax:817-782-9304
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-24
Last Update Date:2013-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX136989261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2645166Medicaid
TX75-2645166OtherADMINISTOR