Provider Demographics
NPI:1568850717
Name:EDGECOMBE, HOLLY ANN (LMT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANN
Last Name:EDGECOMBE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3161 43RD ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8791
Mailing Address - Country:US
Mailing Address - Phone:701-893-2639
Mailing Address - Fax:701-893-2638
Practice Address - Street 1:3161 43RD ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8791
Practice Address - Country:US
Practice Address - Phone:701-893-2639
Practice Address - Fax:701-893-2638
Is Sole Proprietor?:No
Enumeration Date:2014-12-22
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1439225700000X
ND1130225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist