Individual
LISA FANNING ETHERIDGE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP/APRN
Contact information
Practice address
1175 COOK RD STE 320, ORANGEBURG, SC 29118-8247
(803) 395-3960
Mailing address
914 REYNOLDS RD, BARNWELL, SC 29812
(803) 259-5311
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
20081
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
7389
MEDICARE GROUP PTAN
—
Enumeration date
08/15/2016
Last updated
07/21/2022
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