Healthcare Provider Details

I. General information

NPI: 1730017690
Provider Name (Legal Business Name): MICHELLE ETHERINGTON LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5525 GROSSMONT CENTER DR
LA MESA CA
91942-3009
US

IV. Provider business mailing address

9625 PINO DR
LAKESIDE CA
92040-4334
US

V. Phone/Fax

Practice location:
  • Phone: 619-750-3670
  • Fax:
Mailing address:
  • Phone: 619-750-3670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number203996
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: