Provider Demographics
NPI:1396871042
Name:EDWARDS, MELISSA SUE (LMP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:SUE
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:12932 SE KENT KANGLEY RD
Mailing Address - Street 2:#438
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-7940
Mailing Address - Country:US
Mailing Address - Phone:425-392-1814
Mailing Address - Fax:425-392-1813
Practice Address - Street 1:27116 167TH PL SE
Practice Address - Street 2:SUITE 114
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-7341
Practice Address - Country:US
Practice Address - Phone:253-630-6614
Practice Address - Fax:253-630-6624
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA14178OtherPREMERA BLUE CROSS
WA14178OtherAETNA