Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | AP30004776 | WA |
NPI | 1023092392 |
---|---|
Provider Name | Marlene I Bridgforth |
First Address | Tacoma, WA 98405-2308 |
Second Address | Tacoma, WA 98405-2308 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/12/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
9622390 | (05) | WA |
S60902 | (02) |