Provider Demographics
NPI:1760848618
Name:KETTLER, DAWN
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:KETTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1291 E HARVEST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-8625
Mailing Address - Country:US
Mailing Address - Phone:231-943-0786
Mailing Address - Fax:
Practice Address - Street 1:1291 E HARVEST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49685-8625
Practice Address - Country:US
Practice Address - Phone:231-943-0786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704168503163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse