Healthcare Provider Details

I. General information

NPI: 1871099002
Provider Name (Legal Business Name): DESTINY ETHERIDGE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DESTINY DANIELLE SPENCE

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 W BROADWAY STE 107
LOUISVILLE KY
40203-3607
US

IV. Provider business mailing address

1720 W BROADWAY
LOUISVILLE KY
40203-3607
US

V. Phone/Fax

Practice location:
  • Phone: 502-340-5900
  • Fax:
Mailing address:
  • Phone: 502-340-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTP282
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number55932
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number55932
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: