Provider Demographics
NPI:1194244889
Name:KETTEL, LAURA LYNN (DPT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNN
Last Name:KETTEL
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 ORCHARD ST W STE 100
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6610
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:34617 11TH PL S STE 201
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8706
Practice Address - Country:US
Practice Address - Phone:253-815-1117
Practice Address - Fax:253-815-1107
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPT60754995OtherPT LICENSURE