Provider Demographics
NPI:1912419904
Name:KETTERHAGEN, SUZANNE LYNN (HIS)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:LYNN
Last Name:KETTERHAGEN
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 ISLAND ST
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-2351
Mailing Address - Country:US
Mailing Address - Phone:715-726-0931
Mailing Address - Fax:
Practice Address - Street 1:218 ISLAND ST
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-2351
Practice Address - Country:US
Practice Address - Phone:715-726-0931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1531-60237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist