Provider Demographics
NPI:1245923622
Name:BRIDGES, RAETTA DAWN (FNP)
Entity type:Individual
Prefix:
First Name:RAETTA
Middle Name:DAWN
Last Name:BRIDGES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SW 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:MINERAL WELLS
Mailing Address - State:TX
Mailing Address - Zip Code:76067-8246
Mailing Address - Country:US
Mailing Address - Phone:940-325-7891
Mailing Address - Fax:
Practice Address - Street 1:400 SW 25TH AVE
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067-8246
Practice Address - Country:US
Practice Address - Phone:940-325-7891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX856097363LF0000X
TX1126344363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily