Provider Demographics
NPI:1841584844
Name:BRODHEAD, HAVILAH NOEL (RN, MSN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:HAVILAH
Middle Name:NOEL
Last Name:BRODHEAD
Suffix:
Gender:F
Credentials:RN, MSN, FNP-BC
Other - Prefix:MRS
Other - First Name:HAVILAH
Other - Middle Name:
Other - Last Name:LIEDERBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2947 NE YELLOW RIBBON DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7657
Mailing Address - Country:US
Mailing Address - Phone:970-275-6108
Mailing Address - Fax:412-550-9475
Practice Address - Street 1:2275 NE DOCTORS DR
Practice Address - Street 2:STE 1
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6324
Practice Address - Country:US
Practice Address - Phone:541-316-5693
Practice Address - Fax:844-395-8842
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-07
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201407546NP-PP363LP2300X
OR201500894NP-PP363LA2100X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500678393Medicaid
OR500678393Medicaid