Healthcare Provider Details

I. General information

NPI: 1366957110
Provider Name (Legal Business Name): KELLI LYNN HUFFSTUTLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

738 SE 148TH AVE
PORTLAND OR
97233-2531
US

IV. Provider business mailing address

738 SE 148TH AVE
PORTLAND OR
97233-2531
US

V. Phone/Fax

Practice location:
  • Phone: 503-551-8126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: