Basic Information
| Provider Information | |||||||||
| NPI: | 1104070598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRIDGELAND | ||||||||
| FirstName: | BRIANNE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34439 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241439 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 W POPLAR ST | ||||||||
| Address2: | SUITE #210 | ||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993622858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095225825 | ||||||||
| FaxNumber: | 5095293512 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2008 | ||||||||
| LastUpdateDate: | 04/19/2012 | ||||||||
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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 | 163W00000X | RN00162116 | WA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | AP60033974 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 500617786 | 05 | OR | MEDICAID | 1104070598 | 05 | WA | MEDICAID |