Healthcare Provider Details

I. General information

NPI: 1770213183
Provider Name (Legal Business Name): KETLIE CAMILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

787 E 46TH ST APT 5D
BROOKLYN NY
11203-5751
US

IV. Provider business mailing address

787 E 46TH ST APT 5D
BROOKLYN NY
11203-5751
US

V. Phone/Fax

Practice location:
  • Phone: 718-629-5467
  • Fax:
Mailing address:
  • Phone: 718-629-5467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number55918701
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: