Healthcare Provider Details

I. General information

NPI: 1629263785
Provider Name (Legal Business Name): DAVID W KETTLEY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 BLACKBERRY TRL
AURORA IL
60506-4261
US

IV. Provider business mailing address

89 BLACKBERRY TRL
AURORA IL
60506-4261
US

V. Phone/Fax

Practice location:
  • Phone: 630-346-3073
  • Fax:
Mailing address:
  • Phone: 630-346-3073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number041307853
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: