Provider Demographics
NPI:1164806956
Name:KETTLEWELL, STACEY JO (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:JO
Last Name:KETTLEWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:JO
Other - Last Name:KETTLEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1 MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-6379
Mailing Address - Country:US
Mailing Address - Phone:304-243-3000
Mailing Address - Fax:304-243-3060
Practice Address - Street 1:1 MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-6379
Practice Address - Country:US
Practice Address - Phone:304-243-3000
Practice Address - Fax:304-243-3060
Is Sole Proprietor?:No
Enumeration Date:2015-07-12
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV363AS0400X
WV1904363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical