Provider Demographics
NPI:1124085931
Name:EDGMON, DONNA MANSUETO (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MANSUETO
Last Name:EDGMON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4197 TARA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-7944
Mailing Address - Country:US
Mailing Address - Phone:479-751-6243
Mailing Address - Fax:479-751-6446
Practice Address - Street 1:2700 AMERICAN ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-6937
Practice Address - Country:US
Practice Address - Phone:479-751-5504
Practice Address - Fax:479-751-6446
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR235235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56124OtherBLUE CROSS BLUE SHEILD