Provider Demographics
NPI:1811795990
Name:KETTER, KATHERINE QUEEN
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:QUEEN
Last Name:KETTER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 DP NEWMAN CIR
Mailing Address - Street 2:
Mailing Address - City:KIEFER
Mailing Address - State:OK
Mailing Address - Zip Code:74041-3008
Mailing Address - Country:US
Mailing Address - Phone:918-607-8827
Mailing Address - Fax:
Practice Address - Street 1:234 DP NEWMAN CIR
Practice Address - Street 2:
Practice Address - City:KIEFER
Practice Address - State:OK
Practice Address - Zip Code:74041-3008
Practice Address - Country:US
Practice Address - Phone:918-607-8827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKJ083742307171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator