Healthcare Provider Details

I. General information

NPI: 1659326866
Provider Name (Legal Business Name): KETTLY GASTON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: KETTLY JOSEPH PA-C

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 HWY 227
CARROLLTON KY
41008-8037
US

IV. Provider business mailing address

2800 CHELSEA MEADOW WAY
LA GRANGE KY
40031-6755
US

V. Phone/Fax

Practice location:
  • Phone: 502-287-6060
  • Fax:
Mailing address:
  • Phone: 561-654-7296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2891
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: