Provider Demographics
NPI:1043361785
Name:EDWARDS, PAMELA ANN
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:ANN
Last Name:EDWARDS
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 1:5501 MARVIN SHIELDS BLVD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-9007
Mailing Address - Country:US
Mailing Address - Phone:228-871-4033
Mailing Address - Fax:
Practice Address - Street 1:5502 MARVIN SHIELDS BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-871-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR516619363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
275365OtherANCC NATIONAL CERTIFICATION FNP
MSPH00121281Medicaid