MEDICARE: LISA MICHELE BRIDGES RNC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0808X	Psychiatric/Mental Health Registered Nurse	1051798	KY

General Provider Information

NPI Number	:	1902803497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MICHELE BRIDGES RNC

Provider Business Mailing Address
First Line	:	760 E LAKE RD
Second Line	:
City	:	GRACEY
State	:	KY
Zip	:	42232-9702
Country	:	US
Telephone Number	:	270-235-9387
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 BROADWAY ST
Second Line	:
City	:	PADUCAH
State	:	KY
Zip	:	42001-0713
Country	:	US
Telephone Number	:	270-538-0772
Fax Number	:	270-538-0773

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	07/08/2007

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