Basic Information
Provider Information
NPI: 1033559653
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ETHRIDGE
FirstName: ANNA
MiddleName: H
NamePrefix: MS.
NameSuffix:  
Credential: NP-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 233 MERIWETHER RD NW # NW1
Address2:  
City: MILLEDGEVILLE
State: GA
PostalCode: 310618085
CountryCode: US
TelephoneNumber: 4789680198
FaxNumber:  
Practice Location
Address1: 821 N COBB ST
Address2:  
City: MILLEDGEVILLE
State: GA
PostalCode: 310612343
CountryCode: US
TelephoneNumber: 4784543969
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/27/2013
LastUpdateDate: 06/27/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000XRN173744GAY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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