Provider Demographics
NPI:1629263785
Name:KETTLEY, DAVID W (RN)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:KETTLEY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 BLACKBERRY TRL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-4261
Mailing Address - Country:US
Mailing Address - Phone:630-346-3073
Mailing Address - Fax:
Practice Address - Street 1:89 BLACKBERRY TRL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-4261
Practice Address - Country:US
Practice Address - Phone:630-346-3073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041307853163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy