Provider Demographics
NPI:1053037069
Name:ETHRIDGE, GRETCHEN
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:
Last Name:ETHRIDGE
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 1:206 W JULES VERNE WAY
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-7301
Mailing Address - Country:US
Mailing Address - Phone:919-827-2792
Mailing Address - Fax:
Practice Address - Street 1:206 W JULES VERNE WAY
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-7301
Practice Address - Country:US
Practice Address - Phone:919-827-2792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA-3076461171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach