Provider Demographics
NPI:1487979001
Name:ETHRIDGE, KRISTEN (NP)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:EISTETTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:323-361-4148
Mailing Address - Fax:
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-6062
Practice Address - Country:US
Practice Address - Phone:310-825-9820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA342343363LP0200X
CA10455363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics