Provider Demographics
NPI:1871099002
Name:ETHERIDGE, DESTINY (MD)
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:ETHERIDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DESTINY
Other - Middle Name:DANIELLE
Other - Last Name:SPENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1720 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-3607
Mailing Address - Country:US
Mailing Address - Phone:502-340-5900
Mailing Address - Fax:
Practice Address - Street 1:1720 W BROADWAY STE 107
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-3607
Practice Address - Country:US
Practice Address - Phone:502-340-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP282207Q00000X
KY55932207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine