Provider Demographics
NPI:1235372731
Name:KETTELKAMP, TYLER STEVEN (ATC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:STEVEN
Last Name:KETTELKAMP
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-5246
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8559 EDINBROOK PKWY
Practice Address - Street 2:104
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-3747
Practice Address - Country:US
Practice Address - Phone:763-425-5461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer