Provider Demographics
NPI:1952721631
Name:ETHRIDGE, LINDSEY ELIZABETH
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:ELIZABETH
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDSEY
Other - Middle Name:ELIZABETH
Other - Last Name:TAILLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1735 SWEET BRIAR PL
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-1256
Mailing Address - Country:US
Mailing Address - Phone:805-796-1101
Mailing Address - Fax:
Practice Address - Street 1:1735 SWEET BRIAR PL
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-1256
Practice Address - Country:US
Practice Address - Phone:805-796-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12762174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist