1841584844 NPI number — MRS. HAVILAH NOEL BRODHEAD R.N., MSN, FNP-BC

Table of content: MRS. HAVILAH NOEL BRODHEAD R.N., MSN, FNP-BC (NPI 1841584844)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841584844 NPI number — MRS. HAVILAH NOEL BRODHEAD R.N., MSN, FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRODHEAD
Provider First Name:
HAVILAH
Provider Middle Name:
NOEL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
R.N., MSN, FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LIEDERBACH
Provider Other First Name:
HAVILAH
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1841584844
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2947 NE YELLOW RIBBON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97701-7657
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-275-6108
Provider Business Mailing Address Fax Number:
412-550-9475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2275 NE DOCTORS DR
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97701-6324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-316-5693
Provider Business Practice Location Address Fax Number:
844-395-8842
Provider Enumeration Date:
06/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X , with the licence number:  201407546NP-PP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LA2100X , with the licence number: 201500894NP-PP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500678393 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com