Provider Demographics
NPI:1568635142
Name:EDWARDS, LISA M (PT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
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:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93258-0790
Mailing Address - Country:US
Mailing Address - Phone:559-791-1778
Mailing Address - Fax:559-791-1771
Practice Address - Street 1:25 E THURMAN AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-3709
Practice Address - Country:US
Practice Address - Phone:559-791-1778
Practice Address - Fax:559-791-1771
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24829225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT24829OtherPT LICENSE