Healthcare Provider Details

I. General information

NPI: 1841859295
Provider Name (Legal Business Name): CHARLY RIANA EDMONDS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 OAK GROVE ST
MOUNTAIN VIEW AR
72560-8601
US

IV. Provider business mailing address

2716 WAKEFIELD DR APT G
JONESBORO AR
72404-7792
US

V. Phone/Fax

Practice location:
  • Phone: 870-269-5835
  • Fax: 870-269-2723
Mailing address:
  • Phone: 870-421-3515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA3866
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: