Provider Demographics
NPI:1194373605
Name:ALEXIS, KETTLY MONLIN
Entity Type:Individual
Prefix:
First Name:KETTLY
Middle Name:MONLIN
Last Name:ALEXIS
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 1:11990 NE 16TH AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-6675
Mailing Address - Country:US
Mailing Address - Phone:305-298-9812
Mailing Address - Fax:
Practice Address - Street 1:11990 NE 16TH AVE APT 203
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-6675
Practice Address - Country:US
Practice Address - Phone:305-298-9812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTT15087227800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLTT15087Medicaid