Provider Demographics
NPI:1235663865
Name:KETTELKAMP, TESSA
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:KETTELKAMP
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 1:7 CONCORD LN
Mailing Address - Street 2:
Mailing Address - City:SKILLMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08558-1606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7 CONCORD LN
Practice Address - Street 2:
Practice Address - City:SKILLMAN
Practice Address - State:NJ
Practice Address - Zip Code:08558-1606
Practice Address - Country:US
Practice Address - Phone:908-812-7139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer