MEDICARE: ANN LOUISE KETTNER

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	225200000X	Physical Therapy Assistant	5502003826	MI

General Provider Information

NPI Number	:	1508431834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANN LOUISE KETTNER

Provider Business Mailing Address
First Line	:	3152 PEREGRINE DR NE STE 115
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9723
Country	:	US
Telephone Number	:	616-643-0833
Fax Number	:	616-643-0844

Provider Business Practice Location Address
First Line	:	3152 PEREGRINE DR NE STE 115
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49525-9723
Country	:	US
Telephone Number	:	616-643-0833
Fax Number	:	161-643-0844

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

Provider Enumeration Date	:	05/20/2021
Last Update Date	:	05/20/2021

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Directions to “ ANN LOUISE KETTNER ” Practice Location

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