Provider Demographics
NPI:1942317557
Name:PETERSON, BRIDGETTE MONIQUE
Entity type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:MONIQUE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRIDGETTE
Other - Middle Name:MONIQUE
Other - Last Name:LESLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1452 CHAIN BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3706
Mailing Address - Country:US
Mailing Address - Phone:703-356-5900
Mailing Address - Fax:
Practice Address - Street 1:1452 CHAIN BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3706
Practice Address - Country:US
Practice Address - Phone:703-356-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00109200363LF0000X
CA95004154363LF0000X
VA0024182741363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ123579XVAMedicare UPIN