Provider Demographics
NPI:1063920007
Name:CAMILLE, KETLY (RN)
Entity type:Individual
Prefix:MRS
First Name:KETLY
Middle Name:
Last Name:CAMILLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KETLY
Other - Middle Name:
Other - Last Name:CAMILLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:5726 LINCOLN CIR E
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-6757
Mailing Address - Country:US
Mailing Address - Phone:561-812-3976
Mailing Address - Fax:
Practice Address - Street 1:5726 LINCOLN CIR E
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-6757
Practice Address - Country:US
Practice Address - Phone:156-812-3976
Practice Address - Fax:561-828-7627
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9428268163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid