Provider Demographics
NPI:1932855970
Name:EDWARDS, LAVONNE (PA)
Entity Type:Individual
Prefix:
First Name:LAVONNE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-3341
Mailing Address - Country:US
Mailing Address - Phone:410-535-6975
Mailing Address - Fax:
Practice Address - Street 1:131 MAIN ST
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3336
Practice Address - Country:US
Practice Address - Phone:410-535-6975
Practice Address - Fax:410-535-6915
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0008127363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant