Provider Demographics
NPI:1053893412
Name:HUGGINS, DIEDRA SHANEL (RN)
Entity type:Individual
Prefix:MRS
First Name:DIEDRA
Middle Name:SHANEL
Last Name:HUGGINS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 SANTEE RUN ROAD
Mailing Address - Street 2:
Mailing Address - City:HUNDRED
Mailing Address - State:WV
Mailing Address - Zip Code:26575
Mailing Address - Country:US
Mailing Address - Phone:304-775-4153
Mailing Address - Fax:
Practice Address - Street 1:333 FOUNDRY STREET
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155
Practice Address - Country:US
Practice Address - Phone:304-455-2441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-02
Last Update Date:2018-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV57567163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1427238583Medicaid