Provider Demographics
NPI:1912263609
Name:KETTER, KIMBERLY A (AGNP-C)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:A
Last Name:KETTER
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 38004
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231-0804
Mailing Address - Country:US
Mailing Address - Phone:804-873-8389
Mailing Address - Fax:804-324-5049
Practice Address - Street 1:700 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-5802
Practice Address - Country:US
Practice Address - Phone:804-324-5051
Practice Address - Fax:804-324-5049
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-06
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001142669163WD0400X
VA0024173081363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator