Provider Demographics
NPI:1427064948
Name:KETTERHAGEN, DEBRA L (APNP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:L
Last Name:KETTERHAGEN
Suffix:
Gender:F
Credentials:APNP
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Mailing Address - Street 1:N17W24100 RIVERWOOD DR
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES, INC.
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1177
Mailing Address - Country:US
Mailing Address - Phone:262-928-4100
Mailing Address - Fax:262-928-5835
Practice Address - Street 1:725 AMERICAN AVE
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES, INC.
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5031
Practice Address - Country:US
Practice Address - Phone:262-928-3500
Practice Address - Fax:262-544-0382
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2011-11-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI2160-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36011100Medicaid
WI36011100Medicaid