Provider Demographics
NPI:1841859295
Name:EDMONDS, CHARLY RIANA (PTA)
Entity type:Individual
Prefix:
First Name:CHARLY
Middle Name:RIANA
Last Name:EDMONDS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 WAKEFIELD DR APT G
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-7792
Mailing Address - Country:US
Mailing Address - Phone:870-421-3515
Mailing Address - Fax:
Practice Address - Street 1:706 OAK GROVE ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:AR
Practice Address - Zip Code:72560-8601
Practice Address - Country:US
Practice Address - Phone:870-269-5835
Practice Address - Fax:870-269-2723
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA3866225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant