Provider Demographics
NPI:1821574310
Name:ETHERIDGE, KELLEY LARSON (APRN/CRNA)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:LARSON
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:APRN/CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 BLACK WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06422-1400
Mailing Address - Country:US
Mailing Address - Phone:860-575-2052
Mailing Address - Fax:
Practice Address - Street 1:114 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1208
Practice Address - Country:US
Practice Address - Phone:860-714-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7675367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered