Provider Demographics
NPI:1285890632
Name:ETHERIDGE, PATRICIA LYNN (PT)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LYNN
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:WOOD
Other - Last Name:ETHERIDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1727 LILABERRY LANE
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8742
Mailing Address - Country:US
Mailing Address - Phone:850-897-1805
Mailing Address - Fax:
Practice Address - Street 1:1727 LILABERRY LANE
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8742
Practice Address - Country:US
Practice Address - Phone:850-687-4167
Practice Address - Fax:850-807-6677
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 241372251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics