MEDICARE: AUDRA HUDDLESTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	LP049870	AZ

General Provider Information

NPI Number	:	1790036416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDRA HUDDLESTON

Provider Business Mailing Address
First Line	:	10944 W GRISWOLD RD
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85345-2997
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 7TH AVE W
Second Line	:
City	:	BUCKEYE
State	:	AZ
Zip	:	85326-1020
Country	:	US
Telephone Number	:	623-386-4487
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2012
Last Update Date	:	11/17/2015

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Directions to “ AUDRA HUDDLESTON ” Practice Location

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