Provider Demographics
NPI:1689670994
Name:KETT, KATHLEEN M (CNM)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:KETT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-1648
Mailing Address - Country:US
Mailing Address - Phone:715-284-2003
Mailing Address - Fax:844-285-4399
Practice Address - Street 1:502 MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-1648
Practice Address - Country:US
Practice Address - Phone:715-284-2003
Practice Address - Fax:844-285-4399
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55872367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43812000Medicaid
S87123Medicare UPIN
WI0034Medicare PIN