Provider Demographics
NPI:1649771155
Name:ETHERIDGE, TORY KIRSTEN (NP)
Entity Type:Individual
Prefix:
First Name:TORY
Middle Name:KIRSTEN
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:688 WALNUT ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-0333
Mailing Address - Country:US
Mailing Address - Phone:478-742-7566
Mailing Address - Fax:478-743-2804
Practice Address - Street 1:688 WALNUT ST STE 200
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-0333
Practice Address - Country:US
Practice Address - Phone:478-742-7566
Practice Address - Fax:478-743-2804
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2017026648363LA2100X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RN223023OtherGA LICENSE