Healthcare Provider Details

I. General information

NPI: 1881513323
Provider Name (Legal Business Name): KYLE KETTERER AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 MADISON AVE
GRANITE CITY IL
62040-4701
US

IV. Provider business mailing address

2100 MADISON AVE
GRANITE CITY IL
62040-4701
US

V. Phone/Fax

Practice location:
  • Phone: 618-798-3260
  • Fax: 618-798-3716
Mailing address:
  • Phone: 618-798-3260
  • Fax: 618-798-3716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number041403323
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: