Provider Demographics
NPI:1790040681
Name:KETNER, TERRI
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:KETNER
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:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1978
Mailing Address - Country:US
Mailing Address - Phone:575-623-1480
Mailing Address - Fax:575-622-3325
Practice Address - Street 1:110 E MESCALERO RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-6542
Practice Address - Country:US
Practice Address - Phone:575-623-1480
Practice Address - Fax:575-622-3325
Is Sole Proprietor?:No
Enumeration Date:2012-07-07
Last Update Date:2012-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator