Basic Information
| Provider Information | |||||||||
| NPI: | 1346635430 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | KENIA | ||||||||
| MiddleName: | IMANI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | ATTN: CREDENTIALING/PAYER ENROLLMENT | ||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 315 MERCY AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953408368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095643700 | ||||||||
| FaxNumber: | 2095643799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2015 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A161805 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | A161805 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.