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General NPI Number Information
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NPI Number | 1871470682
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Entity Type | Individual
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Provider Name | MARANDA BROOKE ETHEREDGE AGACNP-BC
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Gender | Female
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Dates
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Enumeration Date | 08/21/2025
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 2710 SWISS AVE
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City | DALLAS
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State | TX
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Zip | 75204-5900
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Country | US
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Telephone | 214-821-1599
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Fax |
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Provider Business Mailing Address
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Address Line | 3610 GILLESPIE ST APT 6
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City | DALLAS
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State | TX
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Zip | 75219-4979
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Country | US
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Telephone | 918-845-6053
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 1212740
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License Number State | TX
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