Provider Demographics
NPI:1447025077
Name:EDWARDS, SHONTRELLE
Entity type:Individual
Prefix:
First Name:SHONTRELLE
Middle Name:
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 1:643 N ROYAL TOWER DR
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2603
Mailing Address - Country:US
Mailing Address - Phone:803-722-9866
Mailing Address - Fax:
Practice Address - Street 1:10320 FARROW RD STE B
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-9109
Practice Address - Country:US
Practice Address - Phone:803-722-9866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care