Healthcare Provider Details

I. General information

NPI: 1841092046
Provider Name (Legal Business Name): BRIDGETTE NIESE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8028 CARNEGIE BLVD STE 300
FORT WAYNE IN
46804-5788
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-6650
  • Fax: 260-755-6233
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28236136A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number09000504A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: