Provider Demographics
NPI:1083940225
Name:THELUSMA, KETLY C (RRT)
Entity Type:Individual
Prefix:
First Name:KETLY
Middle Name:C
Last Name:THELUSMA
Suffix:
Gender:F
Credentials:RRT
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:N/A
Mailing Address - Street 1:2431 SW WEBSTER LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5753
Mailing Address - Country:US
Mailing Address - Phone:772-240-4280
Mailing Address - Fax:
Practice Address - Street 1:2431 SW WEBSTER LN
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-5753
Practice Address - Country:US
Practice Address - Phone:772-240-4280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL100072279H0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredHome Health