Provider Demographics
NPI:1538810239
Name:BRODIE, BRIDGET
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:BRODIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 MOUNT VERNON RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-2906
Mailing Address - Country:US
Mailing Address - Phone:703-945-9857
Mailing Address - Fax:
Practice Address - Street 1:1823 MOUNT VERNON RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-2906
Practice Address - Country:US
Practice Address - Phone:703-945-9857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001275856163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0001275856OtherRN
L-301163OtherIBCLC