Healthcare Provider Details

I. General information

NPI: 1619886447
Provider Name (Legal Business Name): KYLIE EDMONSTON LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 ROBB ST
SUMMIT MS
39666-8241
US

IV. Provider business mailing address

450 PRICE ST
MAGNOLIA MS
39652-3128
US

V. Phone/Fax

Practice location:
  • Phone: 601-276-2200
  • Fax:
Mailing address:
  • Phone: 225-888-4984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number7579
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: