Provider Demographics
NPI:1063852564
Name:ETHRIDGE, BROOKE D (RN)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:D
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:D
Other - Last Name:FIELDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1105 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-3761
Mailing Address - Country:US
Mailing Address - Phone:785-532-7755
Mailing Address - Fax:785-532-6627
Practice Address - Street 1:1105 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-3761
Practice Address - Country:US
Practice Address - Phone:785-532-7755
Practice Address - Fax:785-532-6627
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS113466163WC1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1400XNursing Service ProvidersRegistered NurseCollege Health