Provider Demographics
NPI:1508621921
Name:ST GEORGE, BRIDGET NICHOLE
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:NICHOLE
Last Name:ST GEORGE
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 1:716 J J DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-8359
Mailing Address - Country:US
Mailing Address - Phone:850-867-6100
Mailing Address - Fax:
Practice Address - Street 1:716 J J DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-8359
Practice Address - Country:US
Practice Address - Phone:850-867-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X
FLS326074845220251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services