Provider Demographics
NPI:1417128083
Name:ETHERIDGE, MEREDITH J (APRN)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:J
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MEREDITH
Other - Middle Name:J
Other - Last Name:DAVENPORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:225 MEDICAL CENTER DR STE 304
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7915
Mailing Address - Country:US
Mailing Address - Phone:270-538-5596
Mailing Address - Fax:
Practice Address - Street 1:225 MEDICAL CENTER DR STE 304
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7915
Practice Address - Country:US
Practice Address - Phone:270-538-5596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5182P363L00000X, 363LP0200X
KY3005182363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK245300OtherMEDICARE PTAN
KY7100062510Medicaid
KY7100062510Medicare Oscar/Certification
KY7100062510Medicaid