1912258195 NPI number — MS. BRIDGETT ANN WEKENBORG PNP

Table of content: MS. BRIDGETT ANN WEKENBORG PNP (NPI 1912258195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912258195 NPI number — MS. BRIDGETT ANN WEKENBORG PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEKENBORG
Provider First Name:
BRIDGETT
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILDEHAUS
Provider Other First Name:
BRIDGETT
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912258195
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
404 N KEENE ST
Provider Second Line Business Mailing Address:
DC608.00
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65201-6626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-771-4265
Provider Business Mailing Address Fax Number:
573-219-4292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 N KEENE ST
Provider Second Line Business Practice Location Address:
DC608.00
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65201-6626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-771-4265
Provider Business Practice Location Address Fax Number:
573-219-4292
Provider Enumeration Date:
09/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  2012030997 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1912258195 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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