Provider Demographics
NPI:1912375502
Name:ETHRIDGE, CHEWEAKII (LVN)
Entity Type:Individual
Prefix:
First Name:CHEWEAKII
Middle Name:
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 W MANCHESTER BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90305-2528
Mailing Address - Country:US
Mailing Address - Phone:562-400-3500
Mailing Address - Fax:310-999-6558
Practice Address - Street 1:8033 1/2 70TH ST
Practice Address - Street 2:
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-5440
Practice Address - Country:US
Practice Address - Phone:562-400-3500
Practice Address - Fax:310-742-0142
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-13
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA290133164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse