Provider Demographics
NPI:1235939539
Name:EDWARDS, SHEVONNE
Entity type:Individual
Prefix:
First Name:SHEVONNE
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11219 NELSON AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-4349
Mailing Address - Country:US
Mailing Address - Phone:216-816-5504
Mailing Address - Fax:
Practice Address - Street 1:11219 NELSON AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-4349
Practice Address - Country:US
Practice Address - Phone:216-816-5504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTN765125172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver