Basic Information
| Provider Information | |||||||||
| NPI: | 1083381495 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUDDLESTON | ||||||||
| FirstName: | ALLIE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 VILLAGE PARK WAY UNIT 708 | ||||||||
| Address2: | |||||||||
| City: | SAVOY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618747441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3095338486 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 DEVONSHIRE DR STE B16-18 | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618207337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175312360 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2021 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.