Provider Demographics
NPI:1295177798
Name:PHILISTIN, KETELY (NP)
Entity Type:Individual
Prefix:
First Name:KETELY
Middle Name:
Last Name:PHILISTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 N FLAGLER DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-3428
Mailing Address - Country:US
Mailing Address - Phone:561-642-1000
Mailing Address - Fax:561-952-1805
Practice Address - Street 1:39200 HOOKER HWY STE 101
Practice Address - Street 2:
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-5368
Practice Address - Country:US
Practice Address - Phone:561-642-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9286698363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily