Provider Demographics
NPI:1689122137
Name:KETTLE, WAVANEY M (RN)
Entity Type:Individual
Prefix:
First Name:WAVANEY
Middle Name:M
Last Name:KETTLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:NURSE
Other - Middle Name:
Other - Last Name:WAVE7
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:11709 HOLLY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-2018
Mailing Address - Country:US
Mailing Address - Phone:813-569-9601
Mailing Address - Fax:813-609-6784
Practice Address - Street 1:11709 HOLLY CREEK DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-2018
Practice Address - Country:US
Practice Address - Phone:813-569-9601
Practice Address - Fax:813-609-6784
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9179030171M00000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No171M00000XOther Service ProvidersCase Manager/Care Coordinator