Healthcare Provider Details

I. General information

NPI: 1316865488
Provider Name (Legal Business Name): NIASIA BRIDGEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9135 PISCATAWAY RD STE 410
CLINTON MD
20735-2555
US

IV. Provider business mailing address

4261 QUEEN CT
WALDORF MD
20602-1503
US

V. Phone/Fax

Practice location:
  • Phone: 240-846-5263
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberMD-10272948226
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: