Provider Demographics
NPI:1104399815
Name:EDWARDS, MARIJKE AUGUSTA (DPT)
Entity type:Individual
Prefix:
First Name:MARIJKE
Middle Name:AUGUSTA
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MARIJKE
Other - Middle Name:AUGUSTA
Other - Last Name:DE KONING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 NW NICHOLS AVE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-2423
Mailing Address - Country:US
Mailing Address - Phone:619-417-0389
Mailing Address - Fax:
Practice Address - Street 1:463 TREMONT ST W STE 100
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3743
Practice Address - Country:US
Practice Address - Phone:360-874-0745
Practice Address - Fax:360-874-0846
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60917166225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPT60917166OtherPT LICENSE