Provider Demographics
NPI:1942767249
Name:MONTFORD, BRIDGETTE FONDA
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:FONDA
Last Name:MONTFORD
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 1:1253 MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-2132
Mailing Address - Country:US
Mailing Address - Phone:863-838-6321
Mailing Address - Fax:
Practice Address - Street 1:1253 MITCHELL ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-2132
Practice Address - Country:US
Practice Address - Phone:863-838-6321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-23
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL92698376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty