MEDICARE: MRS. KELLI NICOLE BRIDGMAN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	RN164274	GA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	ME73316	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588841977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLI NICOLE BRIDGMAN NP

Provider Business Mailing Address
First Line	:	1690 DUNN AVE APT 718
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-1477
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	804 DUNLAWTON AVE STE 1
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-4931
Country	:	US
Telephone Number	:	386-767-8584
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2008
Last Update Date	:	03/27/2023

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