Provider Demographics
NPI:1619206885
Name:ETHRIDGE, ANGELA D (ARNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:D
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3532 EPHRAIM MCDOWELL DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-3224
Mailing Address - Country:US
Mailing Address - Phone:502-882-7172
Mailing Address - Fax:502-882-7151
Practice Address - Street 1:3532 EPHRAIM MCDOWELL DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-3224
Practice Address - Country:US
Practice Address - Phone:502-882-7172
Practice Address - Fax:502-882-7151
Is Sole Proprietor?:No
Enumeration Date:2009-12-16
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006302363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000746393OtherANTHEM
KY7100109880Medicaid
KY50036061OtherPASSPORT HEALTH PLAN
KY7100109880Medicaid
KY50036061OtherPASSPORT HEALTH PLAN