Provider Demographics
NPI:1225832561
Name:ETHERIDGE, KRISTINA LYNN
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LYNN
Last Name:ETHERIDGE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3558 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-8165
Mailing Address - Country:US
Mailing Address - Phone:915-246-6045
Mailing Address - Fax:
Practice Address - Street 1:40 11TH ST
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1817
Practice Address - Country:US
Practice Address - Phone:218-879-4559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-04
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical