Provider Demographics
NPI:1588151567
Name:EDWARDS, LISA ANN (PPCNP-BC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25647 REDWOOD HWY
Mailing Address - Street 2:
Mailing Address - City:CAVE JUNCTION
Mailing Address - State:OR
Mailing Address - Zip Code:97523-9332
Mailing Address - Country:US
Mailing Address - Phone:541-592-4111
Mailing Address - Fax:
Practice Address - Street 1:25647 REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:CAVE JUNCTION
Practice Address - State:OR
Practice Address - Zip Code:97523-9332
Practice Address - Country:US
Practice Address - Phone:541-500-8407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201801351NP-PP363LP0200X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500743373Medicaid