Provider Demographics
NPI:1326501461
Name:BRIDGEFARMER, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BRIDGEFARMER
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 1:415 WHITNEY DR
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:TX
Mailing Address - Zip Code:75173-8344
Mailing Address - Country:US
Mailing Address - Phone:214-808-8710
Mailing Address - Fax:
Practice Address - Street 1:415 WHITNEY DR
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:TX
Practice Address - Zip Code:75173-8344
Practice Address - Country:US
Practice Address - Phone:214-808-8710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-06
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT87638133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123456Medicaid