Provider Demographics
NPI:1376823609
Name:JEAN-LOUIS, KETLY M (LPN)
Entity type:Individual
Prefix:MS
First Name:KETLY
Middle Name:M
Last Name:JEAN-LOUIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 CASTLETON AVE
Mailing Address - Street 2:#1-4
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3038
Mailing Address - Country:US
Mailing Address - Phone:718-273-1914
Mailing Address - Fax:
Practice Address - Street 1:182 CASTLETON AVE
Practice Address - Street 2:#1-4
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3038
Practice Address - Country:US
Practice Address - Phone:718-273-1914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300754-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse