Healthcare Provider Details

I. General information

NPI: 1982856449
Provider Name (Legal Business Name): LINDA ETHERIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15050 NE 20TH ST
WILLISTON FL
32696-8846
US

IV. Provider business mailing address

15050 NE 20TH ST
WILLISTON FL
32696-8846
US

V. Phone/Fax

Practice location:
  • Phone: 352-538-7727
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 1649222
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN 1649222
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN 1649222
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: