Healthcare Provider Details

I. General information

NPI: 1003130584
Provider Name (Legal Business Name): DAWN EVE KETTLEHAKE R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2010
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 W JACKSON RD
SPRINGFIELD OH
45502-7926
US

IV. Provider business mailing address

2910 W JACKSON RD
SPRINGFIELD OH
45502-7926
US

V. Phone/Fax

Practice location:
  • Phone: 937-602-5893
  • Fax:
Mailing address:
  • Phone: 937-602-5893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN277114
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: