Healthcare Provider Details

I. General information

NPI: 1982180337
Provider Name (Legal Business Name): AMBER BROOKE ETHERIDGE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 07/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201
US

IV. Provider business mailing address

309 JACKSON ST
MONROE LA
71201-7407
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-1373
  • Fax:
Mailing address:
  • Phone: 318-966-1373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN141440
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10177
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: