=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477460020
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KETTMAN PSYCHIATRIC PRACTICE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2026
-----------------------------------------------------
Last Update Date | 08/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 PLAZA CIR STE A
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50701-5139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-236-7720
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 310674
-----------------------------------------------------
City | NEW BRAUNFELS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78131-0674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-236-7720
-----------------------------------------------------
Fax | 319-236-7739
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING ADMIN
-----------------------------------------------------
Name | KIMBERLY ADAME
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 830-320-3852
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------