Provider Demographics
NPI:1043472467
Name:HUDDLESTON, KELLY LYNN (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:HUDDLESTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:LEBLANC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9103 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-2440
Mailing Address - Country:US
Mailing Address - Phone:225-927-1190
Mailing Address - Fax:225-706-0160
Practice Address - Street 1:9103 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-2440
Practice Address - Country:US
Practice Address - Phone:225-927-1190
Practice Address - Fax:225-706-0160
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant