Basic Information
| Provider Information | |||||||||
| NPI: | 1164723581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRIDGES | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14721 STEPHENSON RD | ||||||||
| Address2: | |||||||||
| City: | MORNING VIEW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410639641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593562716 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | EDGEWOOD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593012211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2010 | ||||||||
| LastUpdateDate: | 06/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 086672 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 1093910 | KY | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 000000691770 | 01 | ANTHEM | OTHER | 611077369 1295716850 | 01 | HEALTHNET | OTHER | 201006220 | 05 | IN | MEDICAID | 3120830 | 05 | OH | MEDICAID | 7100146110 | 05 | KY | MEDICAID |