Provider Demographics
NPI:1174066930
Name:ETHEREDGE, ANGELIA
Entity type:Individual
Prefix:
First Name:ANGELIA
Middle Name:
Last Name:ETHEREDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-5335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31249 COUNTY ROAD 435
Practice Address - Street 2:
Practice Address - City:SORRENTO
Practice Address - State:FL
Practice Address - Zip Code:32776-7525
Practice Address - Country:US
Practice Address - Phone:407-309-0406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA15599224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant