MEDICARE: KRISTINA MARIE ETHERIDGE NP

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	363L00000X	Nurse Practitioner	F02250519	TX

General Provider Information

NPI Number	:	1730987819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINA MARIE ETHERIDGE NP

Provider Business Mailing Address
First Line	:	1018 N ZANG BLVD STE 110
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-4123
Country	:	US
Telephone Number	:	972-266-8765
Fax Number	:	972-266-5511

Provider Business Practice Location Address
First Line	:	1018 N ZANG BLVD STE 110
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-4123
Country	:	US
Telephone Number	:	972-266-8765
Fax Number	:	972-266-5511

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

Provider Enumeration Date	:	03/05/2025
Last Update Date	:	01/15/2026

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