Healthcare Provider Details

I. General information

NPI: 1912258195
Provider Name (Legal Business Name): BRIDGETT ANN WEKENBORG PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRIDGETT ANN GILDEHAUS

II. Dates (important events)

Enumeration Date: 09/27/2012
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 N KEENE ST DC608.00
COLUMBIA MO
65201-6626
US

IV. Provider business mailing address

404 N KEENE ST DC608.00
COLUMBIA MO
65201-6626
US

V. Phone/Fax

Practice location:
  • Phone: 573-771-4265
  • Fax: 573-219-4292
Mailing address:
  • Phone: 573-771-4265
  • Fax: 573-219-4292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2012030997
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: