Provider Demographics
NPI:1053048272
Name:GADDIS, ANNIE
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:GADDIS
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 1:1820 SUSAN AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3326
Mailing Address - Country:US
Mailing Address - Phone:360-953-0618
Mailing Address - Fax:
Practice Address - Street 1:1128 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3831
Practice Address - Country:US
Practice Address - Phone:360-261-6930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-07
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program