Provider Demographics
NPI:1609191261
Name:RABIDEAU, BRIDGET JAYLENE
Entity Type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:JAYLENE
Last Name:RABIDEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:BRIDGET
Other - Middle Name:JAYLENE
Other - Last Name:HERNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:155 FINNY BLVD
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953
Mailing Address - Country:US
Mailing Address - Phone:518-483-0109
Mailing Address - Fax:518-483-0115
Practice Address - Street 1:155 FINNY BLVD
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953
Practice Address - Country:US
Practice Address - Phone:518-483-0109
Practice Address - Fax:518-483-0115
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009005-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01995615Medicaid