Provider Demographics
NPI:1922338698
Name:PENICK, BRIDGET ERIN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:ERIN
Last Name:PENICK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:BRIDGET
Other - Middle Name:ERIN
Other - Last Name:GRIMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 30180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:435-632-1350
Mailing Address - Fax:
Practice Address - Street 1:1380 E MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790
Practice Address - Country:US
Practice Address - Phone:435-251-2992
Practice Address - Fax:435-688-6222
Is Sole Proprietor?:No
Enumeration Date:2010-01-02
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT268585-4405363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVGG677ZMedicare PIN