Provider Demographics
NPI:1194113100
Name:ETHRIDGE, KRISTEN MARIE
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:MARIE
Last Name:ETHRIDGE
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 1:7185 HARTSFIELD PL
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-3425
Mailing Address - Country:US
Mailing Address - Phone:404-202-2220
Mailing Address - Fax:
Practice Address - Street 1:7185 HARTSFIELD PL
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-3425
Practice Address - Country:US
Practice Address - Phone:404-202-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-26
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008742235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist