Provider Demographics
NPI:1417394487
Name:NIEZER, BRIDGET
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:NIEZER
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 1:8409 HIALEAH LANE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:UM
Mailing Address - Phone:260-246-7048
Mailing Address - Fax:
Practice Address - Street 1:215 DAVIS RD
Practice Address - Street 2:
Practice Address - City:OSSIAN
Practice Address - State:IN
Practice Address - Zip Code:46777-9230
Practice Address - Country:US
Practice Address - Phone:260-622-7821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99057338A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant