Healthcare Provider Details

I. General information

NPI: 1710956420
Provider Name (Legal Business Name): NICOLE EDENS MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 FORSYTHE AVE
MONROE LA
71201-3642
US

IV. Provider business mailing address

2115 FORSYTHE AVE
MONROE LA
71201-3642
US

V. Phone/Fax

Practice location:
  • Phone: 318-388-1303
  • Fax: 318-388-1707
Mailing address:
  • Phone: 318-388-1303
  • Fax: 318-388-1707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number04142
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: