Provider Demographics
NPI:1063713097
Name:KETTNER, ALISHA (CRNA)
Entity type:Individual
Prefix:
First Name:ALISHA
Middle Name:
Last Name:KETTNER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ALISHA
Other - Middle Name:
Other - Last Name:LOPATKIEWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-0800
Mailing Address - Country:US
Mailing Address - Phone:219-864-2268
Mailing Address - Fax:219-864-2649
Practice Address - Street 1:5454 HOHMAN AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-1931
Practice Address - Country:US
Practice Address - Phone:219-933-2270
Practice Address - Fax:219-852-2515
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009914367500000X
IN28183842A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered