Provider Demographics
NPI:1932476108
Name:RICHARD, KETTLY (FNP)
Entity Type:Individual
Prefix:
First Name:KETTLY
Middle Name:
Last Name:RICHARD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2664 HANSEN PL
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4137
Mailing Address - Country:US
Mailing Address - Phone:516-208-9472
Mailing Address - Fax:
Practice Address - Street 1:2664 HANSEN PL
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-4137
Practice Address - Country:US
Practice Address - Phone:516-208-9472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF337017-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily