=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619886447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLIE EDMONSTON LPTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2026
-----------------------------------------------------
Last Update Date | 09/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 709 ROBB ST
-----------------------------------------------------
City | SUMMIT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39666-8241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-276-2200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 PRICE ST
-----------------------------------------------------
City | MAGNOLIA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39652-3128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-888-4984
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 7579
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------