Provider Demographics
NPI:1003832361
Name:BRIDY, JENNIFER LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:BRIDY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:PRIDGEN
Other - Last Name:PEAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:3100 SPRING FOREST RD STE 130
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:888-280-9533
Mailing Address - Fax:919-873-9821
Practice Address - Street 1:1001 SAM PERRY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4453
Practice Address - Country:US
Practice Address - Phone:540-741-7614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2017-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168107367500000X, 367500000X
NC122634367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA12371606Medicaid
VA12371606Medicaid
NC8052139Medicaid
611077369 $$$$$$$$$OtherHEALTHNET
NC560755775OtherCOMMERCIAL
IN200896410Medicaid
KY7100030950Medicaid
KYP00644577Medicare PIN
0918146Medicare PIN
NC2602435Medicare ID - Type UnspecifiedPT B GROUP BILLING #
NC014MROtherBCBS GROUP BILLING #
NC8000311Medicaid