Provider Demographics
NPI:1770213183
Name:CAMILLE, KETLIE
Entity Type:Individual
Prefix:
First Name:KETLIE
Middle Name:
Last Name:CAMILLE
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 1:787 E 46TH ST APT 5D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-5751
Mailing Address - Country:US
Mailing Address - Phone:718-629-5467
Mailing Address - Fax:
Practice Address - Street 1:787 E 46TH ST
Practice Address - Street 2:APT 5D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-5751
Practice Address - Country:US
Practice Address - Phone:718-629-5467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY55918701163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency