Healthcare Provider Details

I. General information

NPI: 1346174273
Provider Name (Legal Business Name): JUSTIN KETTELL FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4414 BENNING RD NE
WASHINGTON DC
20019-4555
US

IV. Provider business mailing address

3600 CUMBERLAND AVE
WACO TX
76707-1106
US

V. Phone/Fax

Practice location:
  • Phone: 202-469-4699
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF05260376
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: