Provider Demographics
NPI:1073660759
Name:ETHERIDGE, KELLEY LYN (ATC)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:LYN
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 WOODSFIELD LN
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-5165
Mailing Address - Country:US
Mailing Address - Phone:404-218-9051
Mailing Address - Fax:
Practice Address - Street 1:52 WOODSFIELD LN
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-5165
Practice Address - Country:US
Practice Address - Phone:404-218-9051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer