Provider Demographics
NPI:1255161543
Name:KETTERLING, SHYLO SOPHIA
Entity type:Individual
Prefix:
First Name:SHYLO
Middle Name:SOPHIA
Last Name:KETTERLING
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SHYLO
Other - Middle Name:SOPHIA
Other - Last Name:COTTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:58646 MCNULTY WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-6210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:58646 MCNULTY WAY
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-6210
Practice Address - Country:US
Practice Address - Phone:503-397-5211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator