Healthcare Provider Details

I. General information

NPI: 1043421332
Provider Name (Legal Business Name): SHARON KATHLEEN ETHEREDGE RD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 E PLAZA DRIVE CHW MARIAN MEDICAL CENTER
SANTA MARIA CA
93454
US

IV. Provider business mailing address

718 E SUNSET AVE
SANTA MARIA CA
93454
US

V. Phone/Fax

Practice location:
  • Phone: 805-739-3791
  • Fax: 805-614-2011
Mailing address:
  • Phone: 805-349-3497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number817145
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: