MEDICARE: MRS. HANNAH ELAINE KETTLE-CHURCH LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN5176488	FL

General Provider Information

NPI Number	:	1316128879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HANNAH ELAINE KETTLE-CHURCH LPN

Provider Business Mailing Address
First Line	:	221 HOSPITAL DR NE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5066
Country	:	US
Telephone Number	:	850-833-9240
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 HUGHES ST NE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-6403
Country	:	US
Telephone Number	:	850-833-3355
Fax Number	:	850-833-3473

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/26/2007
Last Update Date	:	11/26/2007

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