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General NPI Number Information
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NPI Number | 1538562186
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Entity Type | Individual
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Provider Name | KETTELIE GLENN
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Gender | Female
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Dates
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Enumeration Date | 09/26/2014
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Last Update Date | 09/26/2014
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Provider Practice Location Address
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Address Line | 5701 MARY LN
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City | WEST PALM BEACH
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State | FL
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Zip | 33407-1643
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Country | US
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Telephone | 561-574-6460
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Fax |
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Provider Business Mailing Address
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Address Line | 6953 MITCHELL STREET
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City | JUPITER
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State | FL
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Zip | 33458
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Country | US
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Telephone | 561-574-6460
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385H00000X
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Taxonomy Name | Respite Care
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License Number | 6906689
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License Number State | FL
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