MEDICARE: MRS. AMY P ETHERIDGE RN

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	163WS0200X	School Registered Nurse	61856	SC

General Provider Information

NPI Number	:	1437759222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMY P ETHERIDGE RN

Provider Business Mailing Address
First Line	:	3650 PARK AVENUE BLVD
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-7242
Country	:	US
Telephone Number	:	843-856-8060
Fax Number	:

Provider Business Practice Location Address
First Line	:	3650 PARK AVENUE BLVD
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-7242
Country	:	US
Telephone Number	:	843-856-8060
Fax Number	:	843-881-4247

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

Provider Enumeration Date	:	10/29/2020
Last Update Date	:	10/29/2020

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