Provider Demographics
NPI:1043421332
Name:ETHEREDGE, SHARON KATHLEEN (RD CDE)
Entity Type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:KATHLEEN
Last Name:ETHEREDGE
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 E SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454
Mailing Address - Country:US
Mailing Address - Phone:805-349-3497
Mailing Address - Fax:
Practice Address - Street 1:505 E PLAZA DRIVE
Practice Address - Street 2:CHW MARIAN MEDICAL CENTER
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454
Practice Address - Country:US
Practice Address - Phone:805-739-3791
Practice Address - Fax:805-614-2011
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA817145133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAM050107Medicare ID - Type Unspecified
WNT 817145AMedicare UPIN