Provider Demographics
NPI:1295133908
Name:EMBREE, EDEN
Entity type:Individual
Prefix:MISS
First Name:EDEN
Middle Name:
Last Name:EMBREE
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 1:3412 HICKORY HILL TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6087
Mailing Address - Country:US
Mailing Address - Phone:260-452-5559
Mailing Address - Fax:
Practice Address - Street 1:1001 E. 17TH STREET
Practice Address - Street 2:ASSEMBLY HALL
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408
Practice Address - Country:US
Practice Address - Phone:812-855-4509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program