Provider Demographics
NPI:1417108713
Name:KETTLETY, KAREN (LAC)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:KETTLETY
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37629 WOODS LN
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97870-6610
Mailing Address - Country:US
Mailing Address - Phone:541-893-3090
Mailing Address - Fax:
Practice Address - Street 1:1668 RESORT ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-3940
Practice Address - Country:US
Practice Address - Phone:541-893-3090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00947171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist