Provider Demographics
NPI:1598952376
Name:KEITEL, HEATHER A (RN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:KEITEL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-2805
Mailing Address - Country:US
Mailing Address - Phone:920-627-0139
Mailing Address - Fax:
Practice Address - Street 1:1718 N 3RD ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-2805
Practice Address - Country:US
Practice Address - Phone:920-627-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI151529-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35010000Medicaid