Provider Demographics
NPI:1609001148
Name:WILLIS, BRIDGETTE MICHELLE
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:MICHELLE
Last Name:WILLIS
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 1:1402 VENTNOR AVE
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-2733
Mailing Address - Country:US
Mailing Address - Phone:727-938-3631
Mailing Address - Fax:
Practice Address - Street 1:1402 VENTNOR AVE
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-2733
Practice Address - Country:US
Practice Address - Phone:727-938-3631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist