Provider Demographics
NPI:1114969524
Name:DEVARISTE, KETTELY
Entity Type:Individual
Prefix:
First Name:KETTELY
Middle Name:
Last Name:DEVARISTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13421 BRISTOL PARK WAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-7835
Mailing Address - Country:US
Mailing Address - Phone:239-225-7905
Mailing Address - Fax:
Practice Address - Street 1:3622 NE 13TH AVE
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-6415
Practice Address - Country:US
Practice Address - Phone:239-292-2233
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9181978163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care