Provider Demographics
NPI:1164723581
Name:BRIDGES, KIM MICHELLE (MSNA)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MICHELLE
Last Name:BRIDGES
Suffix:
Gender:F
Credentials:MSNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14721 STEPHENSON RD
Mailing Address - Street 2:
Mailing Address - City:MORNING VIEW
Mailing Address - State:KY
Mailing Address - Zip Code:41063-9641
Mailing Address - Country:US
Mailing Address - Phone:859-356-2716
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY086672367500000X
KY1093910163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000691770OtherANTHEM
611077369 1295716850OtherHEALTHNET
IN201006220Medicaid
OH3120830Medicaid
KY7100146110Medicaid
OH3120830Medicaid
$$$$$$$$$00OtherBUREAU OF WORKERS COMP
P400035159Medicare PIN
OH3120830Medicaid
OHP01030512Medicare PIN