Healthcare Provider Details

I. General information

NPI: 1164072591
Provider Name (Legal Business Name): MARY KATHERINE BRIDGES FNP, AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 GAUSE BLVD
SLIDELL LA
70458-2939
US

IV. Provider business mailing address

12078 GRAND OAKS DR
GULFPORT MS
39503-5683
US

V. Phone/Fax

Practice location:
  • Phone: 985-280-2200
  • Fax:
Mailing address:
  • Phone: 865-228-4036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number906858
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number226773
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number927072
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: