Healthcare Provider Details

I. General information

NPI: 1609903376
Provider Name (Legal Business Name): KETTLY KIMBERLYNN CASIMIR CRNP F
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12171 SW 268TH ST
HOMESTEAD FL
33032-8001
US

IV. Provider business mailing address

12171 SW 268TH ST
HOMESTEAD FL
33032-8001
US

V. Phone/Fax

Practice location:
  • Phone: 305-278-0200
  • Fax:
Mailing address:
  • Phone: 305-278-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR158892
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN1005964
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP2596372
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberR0088547
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4288531
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: