MEDICARE: MR. JERRY ETHRIDGE

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	163W00000X	Registered Nurse	RN188111	GA

General Provider Information

NPI Number	:	1851259105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY ETHRIDGE

Provider Business Mailing Address
First Line	:	820 ASHLEY LAINE WALK
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30043-4286
Country	:	US
Telephone Number	:	229-392-3459
Fax Number	:

Provider Business Practice Location Address
First Line	:	820 ASHLEY LAINE WALK
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30043-4286
Country	:	US
Telephone Number	:	229-392-3459
Fax Number	:

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

Provider Enumeration Date	:	01/14/2026
Last Update Date	:	01/14/2026

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