Provider Demographics
NPI:1588841977
Name:BRIDGMAN, KELLI NICOLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:NICOLE
Last Name:BRIDGMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 DUNN AVE APT 718
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1477
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:804 DUNLAWTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4931
Practice Address - Country:US
Practice Address - Phone:386-767-8584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN164274363LA2200X
FLME73316363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA448879182AMedicaid
GAH400113952Medicare UPIN