Provider Demographics
NPI:1598210858
Name:LETANG, KETTY (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KETTY
Middle Name:
Last Name:LETANG
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6586 HYPOLUXO RD STE 334
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-7678
Mailing Address - Country:US
Mailing Address - Phone:877-412-7272
Mailing Address - Fax:
Practice Address - Street 1:12989 SOUTHERN BLVD STE 202
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9291
Practice Address - Country:US
Practice Address - Phone:877-412-7272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9231356363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily