Healthcare Provider Details

I. General information

NPI: 1356083380
Provider Name (Legal Business Name): JACQUELINE MAHONY BRIDGE DNP, APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 07/11/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 CONSTITUTION BLVD S
SHELTON CT
06484-4351
US

IV. Provider business mailing address

25 CONSTITUTION BLVD S
SHELTON CT
06484-4351
US

V. Phone/Fax

Practice location:
  • Phone: 203-924-7334
  • Fax: 203-922-0004
Mailing address:
  • Phone: 203-924-7334
  • Fax: 203-922-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10727
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number135754
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: