Provider Demographics
NPI:1720449457
Name:EDGE, MYSTI NICOLE
Entity type:Individual
Prefix:MS
First Name:MYSTI
Middle Name:NICOLE
Last Name:EDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 NW 41ST ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-6256
Mailing Address - Country:US
Mailing Address - Phone:405-819-8479
Mailing Address - Fax:
Practice Address - Street 1:3010 NW 41ST ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-6256
Practice Address - Country:US
Practice Address - Phone:405-819-8479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)