Healthcare Provider Details

I. General information

NPI: 1912354960
Provider Name (Legal Business Name): KARISA BRIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96102 MARSH LAKES DR
FERNANDINA BEACH FL
32034-6877
US

IV. Provider business mailing address

96102 MARSH LAKES DR
FERNANDINA BEACH FL
32034-6877
US

V. Phone/Fax

Practice location:
  • Phone: 904-556-6120
  • Fax:
Mailing address:
  • Phone: 904-556-6120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235500000X
TaxonomySpeech/Language/Hearing Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: