Provider Demographics
NPI:1205560208
Name:BALLESTEROS-EDWARDS, AMELIA ROSE
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:ROSE
Last Name:BALLESTEROS-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 1:117 BANKS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-6019
Mailing Address - Country:US
Mailing Address - Phone:386-873-8965
Mailing Address - Fax:
Practice Address - Street 1:2301 ERWIN RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-3736
Practice Address - Country:US
Practice Address - Phone:919-684-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant