Healthcare Provider Details

I. General information

NPI: 1760303689
Provider Name (Legal Business Name): KETTELENE PAUL NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 WOODS LANDING DR
LADY LAKE FL
32159-4307
US

IV. Provider business mailing address

309 WOODS LANDING DR
LADY LAKE FL
32159-4307
US

V. Phone/Fax

Practice location:
  • Phone: 786-286-0717
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11037272
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: