Provider Demographics
NPI:1912593021
Name:ETHEREDGE, KOCYFICA L
Entity Type:Individual
Prefix:
First Name:KOCYFICA
Middle Name:L
Last Name:ETHEREDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 WADMALAW DR
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SC
Mailing Address - Zip Code:29673-7785
Mailing Address - Country:US
Mailing Address - Phone:864-735-0878
Mailing Address - Fax:
Practice Address - Street 1:200 WADMALAW DR
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:SC
Practice Address - Zip Code:29673-7785
Practice Address - Country:US
Practice Address - Phone:864-735-0878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC354301744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management