Provider Demographics
NPI:1265745418
Name:HUDDLESTON, AMANDA KATHLENE DIXON (MOT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KATHLENE DIXON
Last Name:HUDDLESTON
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5052 W WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-6957
Mailing Address - Country:US
Mailing Address - Phone:918-261-4023
Mailing Address - Fax:
Practice Address - Street 1:5052 W WAVERLY RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-6957
Practice Address - Country:US
Practice Address - Phone:918-261-4023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1518225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AROTR2862OtherARKANSAS STATE MEDICAL BOARD
OK1518OtherOKLAHOMA STATE BOARD OF MEDICAL LICENSURE AND SUPERVISION