Healthcare Provider Details

I. General information

NPI: 1255074399
Provider Name (Legal Business Name): KRONDA NICOLE HUDDLESTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2022
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 BROADWAY
FORT WAYNE IN
46807-1509
US

IV. Provider business mailing address

811 E PONTIAC ST
FORT WAYNE IN
46803-3459
US

V. Phone/Fax

Practice location:
  • Phone: 260-704-5466
  • Fax:
Mailing address:
  • Phone: 260-704-5466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28245427A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28245427C
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: