Provider Demographics
NPI:1902488463
Name:EDWARDS, MALISSA
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2154 BRIDGEPORT LOOP
Mailing Address - Street 2:
Mailing Address - City:DISCOVERY BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94505-2323
Mailing Address - Country:US
Mailing Address - Phone:925-529-5840
Mailing Address - Fax:
Practice Address - Street 1:1700 TRILOGY PKWY
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-6731
Practice Address - Country:US
Practice Address - Phone:925-809-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-24
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72756163WM1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)