Provider Demographics
NPI:1548396732
Name:EDWARDS, MELODY ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:MELODY
Middle Name:ANN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6599 WARREN SPUR RD
Mailing Address - Street 2:
Mailing Address - City:MELBA
Mailing Address - State:ID
Mailing Address - Zip Code:83641-5227
Mailing Address - Country:US
Mailing Address - Phone:208-409-3565
Mailing Address - Fax:208-467-9131
Practice Address - Street 1:25 14TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4394
Practice Address - Country:US
Practice Address - Phone:208-465-1890
Practice Address - Fax:208-467-9131
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000922000Medicaid