Healthcare Provider Details

I. General information

NPI: 1063316263
Provider Name (Legal Business Name): EMMA EDGELL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2026
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N PERRYVILLE RD
ROCKFORD IL
61114-8011
US

IV. Provider business mailing address

248 MARK CT
WOODSTOCK IL
60098-4120
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-2000
  • Fax:
Mailing address:
  • Phone: 224-908-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.020665
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: