Provider Demographics
NPI:1164072591
Name:BRIDGES, MARY KATHERINE (FNP, AGACNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:BRIDGES
Suffix:
Gender:F
Credentials:FNP, AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12078 GRAND OAKS DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-5683
Mailing Address - Country:US
Mailing Address - Phone:865-228-4036
Mailing Address - Fax:
Practice Address - Street 1:1001 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2939
Practice Address - Country:US
Practice Address - Phone:985-280-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS927072163W00000X
MS906858363L00000X
LA226773363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
RN289947OtherGEORGIA BOARD OF NURSING