Healthcare Provider Details

I. General information

NPI: 1871221275
Provider Name (Legal Business Name): KETIA M ZUCKSCHWERDT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E CHESTNUT ST UNIT 310
LOUISVILLE KY
40202-5703
US

IV. Provider business mailing address

401 E CHESTNUT ST UNIT 310
LOUISVILLE KY
40202-5703
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-4631
  • Fax: 502-588-4694
Mailing address:
  • Phone: 502-588-4631
  • Fax: 502-588-4694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28166729C
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: