Healthcare Provider Details

I. General information

NPI: 1871715508
Provider Name (Legal Business Name): KELLY SUE HATTERMAN MT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 WOOLWORTH AVE
OMAHA NE
68105-1850
US

IV. Provider business mailing address

8016 OAKWOOD ST
RALSTON NE
68127-3736
US

V. Phone/Fax

Practice location:
  • Phone: 402-346-8800
  • Fax:
Mailing address:
  • Phone: 402-884-1740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number213581
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: