Provider Demographics
NPI:1124539580
Name:HUDDLESTON, LAUREN MICHELLE
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MICHELLE
Last Name:HUDDLESTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-3846
Mailing Address - Country:US
Mailing Address - Phone:870-917-8320
Mailing Address - Fax:
Practice Address - Street 1:1524 MADISON ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-3846
Practice Address - Country:US
Practice Address - Phone:870-917-8320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-12
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant