Basic Information
| Provider Information | |||||||||
| NPI: | 1851422752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIDGES | ||||||||
| FirstName: | MARIE | ||||||||
| MiddleName: | WALLIS | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2720 SUNSET BLVD | ||||||||
| Address2: | ATTN CREDENTIALING | ||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291694810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039367679 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2728 SUNSET BLVD | ||||||||
| Address2: | STE 201 | ||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291694840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039368100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 367A00000X | APRN 647 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
No ID Information.