Provider Demographics
NPI:1215549563
Name:KETTER, TINA RENEE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:RENEE
Last Name:KETTER
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 1:1019 BLUFFVIEW DR
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-3525
Mailing Address - Country:US
Mailing Address - Phone:214-779-3463
Mailing Address - Fax:
Practice Address - Street 1:1019 BLUFFVIEW DR
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-3525
Practice Address - Country:US
Practice Address - Phone:214-779-3463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX338389164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse