Provider Demographics
NPI:1063429702
Name:ETHEREDGE, KALI (DPM)
Entity type:Individual
Prefix:DR
First Name:KALI
Middle Name:
Last Name:ETHEREDGE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11380 PROSPERITY FARMS RD STE 221E
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-3465
Mailing Address - Country:US
Mailing Address - Phone:561-848-7722
Mailing Address - Fax:561-848-7812
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:FL
Practice Address - Zip Code:33403-2503
Practice Address - Country:US
Practice Address - Phone:561-848-7722
Practice Address - Fax:561-848-7812
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001044213E00000X
FLPO3255213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPO3255OtherSTATE LICENSE
GAPOD001044OtherSTATE LICENSE
GAPOD001044OtherSTATE LICENSE
GAPOD001044OtherSTATE LICENSE