Provider Demographics
NPI:1588171128
Name:EDWARDS, STEPHANIE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6880 COBBLESTONE BLVD
Mailing Address - Street 2:STE 2
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-9313
Mailing Address - Country:US
Mailing Address - Phone:662-638-3757
Mailing Address - Fax:
Practice Address - Street 1:1120 E MAIN ST STE 24
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:MS
Practice Address - Zip Code:39350-2300
Practice Address - Country:US
Practice Address - Phone:601-781-8677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS866510363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health