Provider Demographics
NPI:1467614511
Name:BURKE-WAMMACK, BRIDGET KELLIE (LMT)
Entity Type:Individual
Prefix:MS
First Name:BRIDGET
Middle Name:KELLIE
Last Name:BURKE-WAMMACK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 CONSERVANCY DR E
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-6744
Mailing Address - Country:US
Mailing Address - Phone:850-524-6346
Mailing Address - Fax:850-386-5252
Practice Address - Street 1:1235 CONSERVANCY DR E
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-6744
Practice Address - Country:US
Practice Address - Phone:850-524-6346
Practice Address - Fax:850-386-5252
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 18418174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC8161OtherBCBS