Provider Demographics
NPI:1467005140
Name:ETHRIDGE, LISA ANNE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
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:PO BOX 740018
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0018
Mailing Address - Country:US
Mailing Address - Phone:773-759-7550
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:1625 RIO BRAVO BLVD SW STE 36
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-6060
Practice Address - Country:US
Practice Address - Phone:505-777-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM57020363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily