Basic Information
| Provider Information | |||||||||
| NPI: | 1649252297 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | BRIDGETTE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RNC, CNM, WHNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILL | ||||||||
| OtherFirstName: | BRIDGETTE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RNC, CNM, WHNP-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1333 W 5TH ST, STE 110 | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076722522 | ||||||||
| FaxNumber: | 3076723732 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 W 5TH ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076722522 | ||||||||
| FaxNumber: | 3076723732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 12008.111 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 110391101 | 05 | WY | MEDICAID | 114080900 | 05 | WY | MEDICAID | 12008.0111 | 01 | WY | STATE LICENSE NUMBER | OTHER | 0437308 | 05 | MT | MEDICAID | MG0599805 | 01 | WY | DEA NUMBER | OTHER |