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General NPI Number Information
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NPI Number | 1225845993
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Entity Type | Individual
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Provider Name | KAITLYN MARIE ETHERIDGE
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Gender | Female
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Dates
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Enumeration Date | 12/16/2024
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Last Update Date | 12/16/2024
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Provider Practice Location Address
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Address Line | 58 PHYSICIANS DR NW
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City | SUPPLY
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State | NC
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Zip | 28462-4215
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Country | US
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Telephone | 910-755-5437
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Fax |
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Provider Business Mailing Address
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Address Line | 30 TALFORD DR
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City | WENDELL
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State | NC
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Zip | 27591-7586
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Country | US
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Telephone | 919-880-0791
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number |
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License Number State |
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