Healthcare Provider Details

I. General information

NPI: 1841584844
Provider Name (Legal Business Name): HAVILAH NOEL BRODHEAD R.N., MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. HAVILAH LIEDERBACH

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 NE DOCTORS DR STE 1
BEND OR
97701-6324
US

IV. Provider business mailing address

2947 NE YELLOW RIBBON DR
BEND OR
97701-7657
US

V. Phone/Fax

Practice location:
  • Phone: 541-316-5693
  • Fax: 844-395-8842
Mailing address:
  • Phone: 970-275-6108
  • Fax: 412-550-9475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number201407546NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number201500894NP-PP
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500678393
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: