Provider Demographics
NPI:1396200556
Name:KETTEL, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:KETTEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24579 HALL DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-4911
Mailing Address - Country:US
Mailing Address - Phone:440-823-6420
Mailing Address - Fax:
Practice Address - Street 1:24579 HALL DR
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-4911
Practice Address - Country:US
Practice Address - Phone:440-823-6420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty