Provider Demographics
NPI:1710103494
Name:KETOLA, NANCILYN K (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:NANCILYN
Middle Name:K
Last Name:KETOLA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W194S8371 SUMMERIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-8165
Mailing Address - Country:US
Mailing Address - Phone:414-687-1122
Mailing Address - Fax:
Practice Address - Street 1:2315 E MOORELAND ROAD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151
Practice Address - Country:US
Practice Address - Phone:262-798-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2184-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1710103494Medicaid