Provider Demographics
NPI:1982811337
Name:EDWARDS, KELLY (LPN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 DEER MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-7690
Mailing Address - Country:US
Mailing Address - Phone:304-487-8754
Mailing Address - Fax:
Practice Address - Street 1:175 PHILPOT LANE
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:WV
Practice Address - Zip Code:25813
Practice Address - Country:US
Practice Address - Phone:304-254-9262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18155164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse