Provider Demographics
NPI:1225359771
Name:AMUNDSEN, BRIDGET ALICE (RD,LD)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:ALICE
Last Name:AMUNDSEN
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 AMES TER
Mailing Address - Street 2:APARTMENT A
Mailing Address - City:CAMDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04843-1802
Mailing Address - Country:US
Mailing Address - Phone:207-975-5645
Mailing Address - Fax:
Practice Address - Street 1:1 VA MEDICAL CENTER
Practice Address - Street 2:(402/171)
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330
Practice Address - Country:US
Practice Address - Phone:207-623-8411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MED1994133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered