Provider Demographics
NPI:1477985646
Name:KETTERLING, BRANDI LYNNE
Entity Type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:LYNNE
Last Name:KETTERLING
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 1:17630 HEMLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-3908
Mailing Address - Country:US
Mailing Address - Phone:952-484-3974
Mailing Address - Fax:
Practice Address - Street 1:17630 HEMLOCK AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-3908
Practice Address - Country:US
Practice Address - Phone:952-484-3974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA194225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant