Provider Demographics
NPI:1063170249
Name:RISNER, BRIDGET NICOLE
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:NICOLE
Last Name:RISNER
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 1:618 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3214
Mailing Address - Country:US
Mailing Address - Phone:580-447-3030
Mailing Address - Fax:
Practice Address - Street 1:618 W 5TH ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3214
Practice Address - Country:US
Practice Address - Phone:580-447-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist