Provider Demographics
NPI:1063521870
Name:HUDDLESTON, BEVERLY ANN (ARNP)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANN
Last Name:HUDDLESTON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:360-486-6508
Mailing Address - Fax:
Practice Address - Street 1:1000 S SCHEUBER RD
Practice Address - Street 2:PMG SW WA CENTRALIA WOMEN CENTER
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-8877
Practice Address - Country:US
Practice Address - Phone:360-330-8950
Practice Address - Fax:360-330-8955
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004059363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9612268Medicaid
WA9612268Medicaid