Basic Information
| Provider Information | |||||||||
| NPI: | 1952896706 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | EDWARDS | ||||||||
| FirstName: | RAVEN | ||||||||
| MiddleName: | SIMONE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 CRESCENT CENTRE DR STE 600 | ||||||||
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| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370677286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153731350 | ||||||||
| FaxNumber: | 6152219054 | ||||||||
| Practice Location | |||||||||
| Address1: | 3451 GOODMAN RD E STE 108 | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628906953 | ||||||||
| FaxNumber: | 6628906954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2018 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT6541 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.