Healthcare Provider Details

I. General information

NPI: 1477460020
Provider Name (Legal Business Name): KETTMAN PSYCHIATRIC PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 PLAZA CIR STE A
WATERLOO IA
50701-5139
US

IV. Provider business mailing address

PO BOX 310674
NEW BRAUNFELS TX
78131-0674
US

V. Phone/Fax

Practice location:
  • Phone: 319-236-7720
  • Fax:
Mailing address:
  • Phone: 319-236-7720
  • Fax: 319-236-7739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY ADAME
Title or Position: BILLING ADMIN
Credential:
Phone: 830-320-3852