Provider Demographics
NPI:1508431834
Name:KETTNER, ANN LOUISE
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:LOUISE
Last Name:KETTNER
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 1:3152 PEREGRINE DR NE STE 115
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9723
Mailing Address - Country:US
Mailing Address - Phone:616-643-0833
Mailing Address - Fax:616-643-0844
Practice Address - Street 1:3152 PEREGRINE DR NE STE 115
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9723
Practice Address - Country:US
Practice Address - Phone:616-643-0833
Practice Address - Fax:161-643-0844
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003826225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant