MEDICARE: ETHAN BRENT CUNNINGHAM FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	4704328016	MI

General Provider Information

NPI Number	:	1083013577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHAN BRENT CUNNINGHAM FNP-C

Provider Business Mailing Address
First Line	:	523 EDGEWORTHE DR SE
Second Line	:
City	:	ADA
State	:	MI
Zip	:	49301-7809
Country	:	US
Telephone Number	:	616-745-8097
Fax Number	:

Provider Business Practice Location Address
First Line	:	523 EDGEWORTHE DR SE
Second Line	:
City	:	ADA
State	:	MI
Zip	:	49301-7809
Country	:	US
Telephone Number	:	616-745-8097
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2014
Last Update Date	:	05/13/2026

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