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General NPI Number Information
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NPI Number | 1245784669
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Entity Type | Individual
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Provider Name | LISA FANNING ETHERIDGE FNP/APRN
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Gender | Female
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Dates
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Enumeration Date | 08/15/2016
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1175 COOK RD STE 320
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City | ORANGEBURG
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State | SC
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Zip | 29118-8247
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Country | US
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Telephone | 803-395-3960
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Fax |
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Provider Business Mailing Address
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Address Line | 914 REYNOLDS RD
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City | BARNWELL
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State | SC
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Zip | 29812
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Country | US
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Telephone | 803-259-5311
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 20081
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License Number State | SC
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