Provider Demographics
NPI:1013576511
Name:HENRY, KETTELIE (ARNP)
Entity Type:Individual
Prefix:
First Name:KETTELIE
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 S OCEAN DR STE 209
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33019-2915
Mailing Address - Country:US
Mailing Address - Phone:800-226-8874
Mailing Address - Fax:877-366-4776
Practice Address - Street 1:3800 S OCEAN DR STE 209
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33019-2915
Practice Address - Country:US
Practice Address - Phone:877-226-8874
Practice Address - Fax:877-366-4776
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-07
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002547363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily