Provider Demographics
NPI:1083013577
Name:CUNNINGHAM, ETHAN BRENT (FNP-C)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:BRENT
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 EDGEWORTHE DR SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-7809
Mailing Address - Country:US
Mailing Address - Phone:616-745-8097
Mailing Address - Fax:
Practice Address - Street 1:523 EDGEWORTHE DR SE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-7809
Practice Address - Country:US
Practice Address - Phone:616-745-8097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704328016363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care