Provider Demographics
NPI:1982484416
Name:ETHRIDGE, AUDREY DALE (PMHNP-BC, MSN)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:DALE
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:PMHNP-BC, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 HOLLY HILL DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-2340
Mailing Address - Country:US
Mailing Address - Phone:662-432-1221
Mailing Address - Fax:888-836-1221
Practice Address - Street 1:777 HOLLY HILL DR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-2340
Practice Address - Country:US
Practice Address - Phone:662-432-1221
Practice Address - Fax:888-836-0702
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MP2023001592363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health