=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235808254
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANNA BRIDGES NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2021
-----------------------------------------------------
Last Update Date | 09/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 749 CR 466
-----------------------------------------------------
City | LADY LAKE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32159-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-350-5130
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8991 E HIGHWAY 25
-----------------------------------------------------
City | BELLEVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34420-7409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-564-5616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11015035
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------