Provider Demographics
NPI:1043771553
Name:PRIDGEN, NITA ANN
Entity Type:Individual
Prefix:
First Name:NITA
Middle Name:ANN
Last Name:PRIDGEN
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 1:112 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64089-8176
Mailing Address - Country:US
Mailing Address - Phone:816-532-6338
Mailing Address - Fax:
Practice Address - Street 1:112 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:MO
Practice Address - Zip Code:64089-8176
Practice Address - Country:US
Practice Address - Phone:816-532-6338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier