Provider Demographics
NPI:1922785195
Name:ETHERIDGE, KENDRA NICHELLE (MPH)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:NICHELLE
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:566 PATTON RD
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-7391
Mailing Address - Country:US
Mailing Address - Phone:770-584-9424
Mailing Address - Fax:
Practice Address - Street 1:5102 PAULSEN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4601
Practice Address - Country:US
Practice Address - Phone:912-758-3438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program