Provider Demographics
NPI:1437759222
Name:ETHERIDGE, AMY P (RN)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:P
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:E
Other - Last Name:PEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3650 PARK AVENUE BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7242
Mailing Address - Country:US
Mailing Address - Phone:843-856-8060
Mailing Address - Fax:
Practice Address - Street 1:3650 PARK AVENUE BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7242
Practice Address - Country:US
Practice Address - Phone:843-856-8060
Practice Address - Fax:843-881-4247
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC61856163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool