Provider Demographics
NPI:1164072591
Name:BRIDGES, MARY KATHERINE (FNP, AGACNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:BRIDGES
Suffix:
Gender:F
Credentials:FNP, AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 DICKORY AVE APT 369
Mailing Address - Street 2:
Mailing Address - City:RIVER RIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70123-2576
Mailing Address - Country:US
Mailing Address - Phone:865-228-4036
Mailing Address - Fax:
Practice Address - Street 1:200 W ESPLANADE AVE
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2489
Practice Address - Country:US
Practice Address - Phone:504-464-8506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA226773363L00000X
GARN289947363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
RN289947OtherGEORGIA BOARD OF NURSING