Provider Demographics
NPI:1821419706
Name:ABRAHAM, KETLY B
Entity Type:Individual
Prefix:
First Name:KETLY
Middle Name:B
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KETLY
Other - Middle Name:B
Other - Last Name:ABRAHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:4200 AVENUE K APT 2H
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-4914
Mailing Address - Country:US
Mailing Address - Phone:917-202-3603
Mailing Address - Fax:
Practice Address - Street 1:4200 AVENUE K APT 2H
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-4914
Practice Address - Country:US
Practice Address - Phone:917-202-3603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-19
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY317282164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse