Healthcare Provider Details

I. General information

NPI: 1467320481
Provider Name (Legal Business Name): CHAKETTA ETHRIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 MONTLIMAR DR
MOBILE AL
36609-1713
US

IV. Provider business mailing address

2521 GREENLAWN DR
MOBILE AL
36605-5230
US

V. Phone/Fax

Practice location:
  • Phone: 251-660-2360
  • Fax: 251-706-5597
Mailing address:
  • Phone: 251-660-2360
  • Fax: 251-706-5597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1-161631
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: