Healthcare Provider Details

I. General information

NPI: 1386846772
Provider Name (Legal Business Name): DEIDRA MARIE EDWARDS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7075 PULASKI AVE
FORT LEONARD WOOD MO
65473-1041
US

IV. Provider business mailing address

7075 PULASKI AVE
FORT LEONARD WOOD MO
65473-1041
US

V. Phone/Fax

Practice location:
  • Phone: 573-842-2650
  • Fax:
Mailing address:
  • Phone: 573-842-2650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number2005020197
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2005020197
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: