Provider Demographics
NPI:1609028638
Name:ETHEREDGE, ANITA
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:ETHEREDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 SLATE RUN
Mailing Address - Street 2:
Mailing Address - City:DOUGLASSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19518-9250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1047
Practice Address - Country:US
Practice Address - Phone:610-834-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA10008402376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide