Provider Demographics
NPI:1255074399
Name:HUDDLESTON, KRONDA NICOLE
Entity type:Individual
Prefix:
First Name:KRONDA
Middle Name:NICOLE
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 1:811 E PONTIAC ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46803-3459
Mailing Address - Country:US
Mailing Address - Phone:260-704-5466
Mailing Address - Fax:
Practice Address - Street 1:3120 BROADWAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-1509
Practice Address - Country:US
Practice Address - Phone:260-704-5466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-17
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28245427A163W00000X
IN28245427C163W00000X
3747P1801X, 376J00000X, 3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No163W00000XNursing Service ProvidersRegistered Nurse
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker