Healthcare Provider Details

I. General information

NPI: 1376705954
Provider Name (Legal Business Name): MRS. CHRISTINA JOY ETHERIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 TARA CT
BENTON KY
42025-7513
US

IV. Provider business mailing address

127 TARA CT
BENTON KY
42025-7513
US

V. Phone/Fax

Practice location:
  • Phone: 270-527-0750
  • Fax:
Mailing address:
  • Phone: 270-527-0750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: