=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437713633
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENAE B BRIDGES APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2019
-----------------------------------------------------
Last Update Date | 06/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1335 SLIGH BLVD STE 3
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-1110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-841-9025
-----------------------------------------------------
Fax | 321-842-3651
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1335 SLIGH BLVD STE 3
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32806-1110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-841-9025
-----------------------------------------------------
Fax | 321-842-3651
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | AP141454
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | APRN11004171
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------