Provider Demographics
NPI:1225845993
Name:ETHERIDGE, KAITLYN MARIE
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MARIE
Last Name:ETHERIDGE
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 1:30 TALFORD DR
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591-7586
Mailing Address - Country:US
Mailing Address - Phone:919-880-0791
Mailing Address - Fax:
Practice Address - Street 1:58 PHYSICIANS DR NW
Practice Address - Street 2:
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4215
Practice Address - Country:US
Practice Address - Phone:910-755-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist