Provider Demographics
NPI:1144822081
Name:DONOVAN, BRIDGET KATHLEEN (FNP-BC)
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:KATHLEEN
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 SECOND AVE STE 2600
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1129
Mailing Address - Country:US
Mailing Address - Phone:781-487-3838
Mailing Address - Fax:
Practice Address - Street 1:52 SECOND AVE STE 2600
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1129
Practice Address - Country:US
Practice Address - Phone:781-487-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2316524163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110202362AOtherMASSHEALTH