Provider Demographics
NPI:1477829364
Name:EPIPHANIE, BRIDGET (CLC, PCD)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:EPIPHANIE
Suffix:
Gender:F
Credentials:CLC, PCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 PEGGY ANN RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-9076
Mailing Address - Country:US
Mailing Address - Phone:518-796-4558
Mailing Address - Fax:
Practice Address - Street 1:12 PEGGY ANN RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-9076
Practice Address - Country:US
Practice Address - Phone:518-796-4558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA32729174N00000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No374J00000XNursing Service Related ProvidersDoula