Basic Information
| Provider Information | |||||||||
| NPI: | 1649771155 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ETHERIDGE | ||||||||
| FirstName: | TORY | ||||||||
| MiddleName: | KIRSTEN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 688 WALNUT ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312010333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787427566 | ||||||||
| FaxNumber: | 4787432804 | ||||||||
| Practice Location | |||||||||
| Address1: | 688 WALNUT ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312010333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787427566 | ||||||||
| FaxNumber: | 4787432804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2018 | ||||||||
| LastUpdateDate: | 02/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 2017026648 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LG0600X | 2017026648 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | 2017026648 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | RN223023 | 01 | GA LICENSE | OTHER |