MEDICARE: KETTELIE GLENN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	385H00000X	Respite Care	6906689	FL

General Provider Information

NPI Number	:	1538562186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KETTELIE GLENN

Provider Business Mailing Address
First Line	:	6953 MITCHELL STREET
Second Line	:
City	:	JUPITER
State	:	FL
Zip	:	33458
Country	:	US
Telephone Number	:	561-574-6460
Fax Number	:

Provider Business Practice Location Address
First Line	:	5701 MARY LN
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-1643
Country	:	US
Telephone Number	:	561-574-6460
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2014
Last Update Date	:	09/26/2014

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