Provider Demographics
NPI:1023092392
Name:BRIDGFORTH, MARLENE I (ARNP)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:I
Last Name:BRIDGFORTH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MARLENE
Other - Middle Name:I
Other - Last Name:MIUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1901 S CEDAR ST
Mailing Address - Street 2:#301 CARDIAC STUDY CENTER INC PS
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2308
Mailing Address - Country:US
Mailing Address - Phone:253-572-7320
Mailing Address - Fax:253-627-3191
Practice Address - Street 1:1901 S CEDAR ST
Practice Address - Street 2:#301 CARDIAC STUDY CENTER INC PS
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2308
Practice Address - Country:US
Practice Address - Phone:253-572-7320
Practice Address - Fax:253-627-3191
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004776363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9622390Medicaid
S60902Medicare UPIN
WAAB05386Medicare ID - Type Unspecified