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 1:4120 GRAY HWY
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:GA
Mailing Address - Zip Code:31032-6156
Mailing Address - Country:US
Mailing Address - Phone:478-320-2298
Mailing Address - Fax:
Practice Address - Street 1:4120 GRAY HWY
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:GA
Practice Address - Zip Code:31032-6156
Practice Address - Country:US
Practice Address - Phone:478-320-2298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2017026648363LG0600X, 363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
RN223023OtherGA LICENSE