Provider Demographics
NPI:1003890005
Name:KETTEN, CONNIE SWARTZ (MD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:SWARTZ
Last Name:KETTEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 REDGATE AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1515
Mailing Address - Country:US
Mailing Address - Phone:757-668-7007
Mailing Address - Fax:757-668-8658
Practice Address - Street 1:680 OYSTER POINT RD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4570
Practice Address - Country:US
Practice Address - Phone:757-668-4851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237424208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VACG6353Other0101237424
VA177578OtherANTHEM PROVIDER NUMBER