Provider Demographics
NPI:1770836363
Name:KETTINGER, LINDSEY DIANE (DNP, FNP-BC)
Entity Type:Individual
Prefix:DR
First Name:LINDSEY
Middle Name:DIANE
Last Name:KETTINGER
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13955
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29422-3955
Mailing Address - Country:US
Mailing Address - Phone:843-766-7696
Mailing Address - Fax:843-556-5882
Practice Address - Street 1:1477 TOBIAS GADSON BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4794
Practice Address - Country:US
Practice Address - Phone:843-766-7696
Practice Address - Fax:843-556-5882
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2397Medicaid
SCSC0219A634Medicare PIN