Provider Demographics
NPI:1902428543
Name:ETHERIDGE-COLEMAN, CYNTHIA ROSEMARY (RN)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:ROSEMARY
Last Name:ETHERIDGE-COLEMAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 HAYES ST
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-8603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:87 HAYES ST
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-8603
Practice Address - Country:US
Practice Address - Phone:518-209-3801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-16
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1255344163W00000X, 163WX1500X, 163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
No163WX1500XNursing Service ProvidersRegistered NurseOstomy CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1255344Medicaid
VA1255344OtherHMO, PPO