Provider Demographics
NPI:1851506356
Name:JOHNSON-FELLS, BRIDGET
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:JOHNSON-FELLS
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 1:10480 KLEIN ROAD
Mailing Address - Street 2:SUITE 182
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3518
Mailing Address - Country:US
Mailing Address - Phone:228-328-4471
Mailing Address - Fax:
Practice Address - Street 1:10480 KLEIN RD
Practice Address - Street 2:SUITE 182
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3511
Practice Address - Country:US
Practice Address - Phone:228-328-4471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00770492376J00000X
MS06258738385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered376J00000XNursing Service Related ProvidersHomemaker
Not Answered385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770492Medicaid
MS06258738Medicaid