Healthcare Provider Details

I. General information

NPI: 1154813400
Provider Name (Legal Business Name): MS. SONYA RENAE JACKSON HUDDLESTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2018
Last Update Date: 06/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2656 N BUFFALO DR UNIT 1306
LAS VEGAS NV
89128-4812
US

IV. Provider business mailing address

2656 N BUFFALO DR UNIT 1306
LAS VEGAS NV
89128-4812
US

V. Phone/Fax

Practice location:
  • Phone: 702-808-3041
  • Fax: 888-725-8902
Mailing address:
  • Phone: 702-808-3041
  • Fax: 888-725-8902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: