Healthcare Provider Details

I. General information

NPI: 1386171585
Provider Name (Legal Business Name): PATRICIA ANN BRIDEWELL NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2017
Last Update Date: 03/13/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 EAST AVENUE I
LANCASTER CA
93535-1916
US

IV. Provider business mailing address

415 EAST AVENUE I
LANCASTER CA
93535-1916
US

V. Phone/Fax

Practice location:
  • Phone: 661-522-6770
  • Fax:
Mailing address:
  • Phone: 661-522-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number536499
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005599
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2021097528
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95005599
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: