MEDICARE: KATIE ETHERINGTON CNM, WHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	AP61092014	WA
2	367A00000X	Advanced Practice Midwife

General Provider Information

NPI Number	:	1205443637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATIE ETHERINGTON CNM, WHNP-BC

Provider Business Mailing Address
First Line	:	711 N EVERGREEN RD APT 2101
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85201-7551
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	853 WATSON ST N STE 200
Second Line	:
City	:	ENUMCLAW
State	:	WA
Zip	:	98022-3948
Country	:	US
Telephone Number	:	360-367-2970
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2020
Last Update Date	:	09/29/2020

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