Provider Demographics
NPI:1376692053
Name:ETHRIDGE, CARLA JEAN (RN)
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:JEAN
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 S BUCHANAN ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-8026
Mailing Address - Country:US
Mailing Address - Phone:480-786-1825
Mailing Address - Fax:
Practice Address - Street 1:1016 N BURK ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-3473
Practice Address - Country:US
Practice Address - Phone:480-892-6908
Practice Address - Fax:480-813-8240
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN064257374T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel