Provider Demographics
NPI:1245784669
Name:ETHERIDGE, LISA FANNING (FNP/APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:FANNING
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:FNP/APRN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:FANNING
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:914 REYNOLDS RD
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812
Mailing Address - Country:US
Mailing Address - Phone:803-259-5311
Mailing Address - Fax:
Practice Address - Street 1:1175 COOK RD STE 320
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8247
Practice Address - Country:US
Practice Address - Phone:803-395-3960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20081363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
7389OtherMEDICARE GROUP PTAN