Provider Demographics
NPI:1083175848
Name:BRIDGES, LISA RENEE (NP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:RENEE
Last Name:BRIDGES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-2811
Mailing Address - Country:US
Mailing Address - Phone:901-562-9464
Mailing Address - Fax:
Practice Address - Street 1:423 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-2811
Practice Address - Country:US
Practice Address - Phone:901-562-9464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003446363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE