Healthcare Provider Details

I. General information

NPI: 1538024187
Provider Name (Legal Business Name): MISTY DAWN ETHRIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 WASHINGTON ST
MONROE MI
48161-2276
US

IV. Provider business mailing address

4325 PARTRIDGE LN
NEWPORT MI
48166-9190
US

V. Phone/Fax

Practice location:
  • Phone: 734-322-3365
  • Fax: 734-322-3365
Mailing address:
  • Phone: 734-735-7923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3503013844
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: