Provider Demographics
NPI:1912094392
Name:MERCER ETHEREDGE, KIMBERLY LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:LYNN
Last Name:MERCER ETHEREDGE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:LYNN
Other - Last Name:ETHEREDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:4711 N DIXIE HWY STE A
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-3916
Mailing Address - Country:US
Mailing Address - Phone:954-491-8127
Mailing Address - Fax:954-491-2388
Practice Address - Street 1:4711 N DIXIE HWY STE A
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-3916
Practice Address - Country:US
Practice Address - Phone:954-491-8127
Practice Address - Fax:954-491-2388
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8053111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL60795Medicare ID - Type Unspecified