Provider Demographics
NPI:1912258195
Name:WEKENBORG, BRIDGETT ANN (PNP)
Entity Type:Individual
Prefix:MS
First Name:BRIDGETT
Middle Name:ANN
Last Name:WEKENBORG
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:BRIDGETT
Other - Middle Name:ANN
Other - Last Name:GILDEHAUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:404 N KEENE ST
Mailing Address - Street 2:DC608.00
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6626
Mailing Address - Country:US
Mailing Address - Phone:573-771-4265
Mailing Address - Fax:573-219-4292
Practice Address - Street 1:404 N KEENE ST
Practice Address - Street 2:DC608.00
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6626
Practice Address - Country:US
Practice Address - Phone:573-771-4265
Practice Address - Fax:573-219-4292
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012030997363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1912258195Medicaid