Provider Demographics
NPI:1427529759
Name:STCYR, KETTLYNE
Entity type:Individual
Prefix:
First Name:KETTLYNE
Middle Name:
Last Name:STCYR
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 LANTANA RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-6915
Mailing Address - Country:US
Mailing Address - Phone:561-790-8072
Mailing Address - Fax:561-966-5654
Practice Address - Street 1:1021 IVES DAIRY RD STE 115
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33179-2537
Practice Address - Country:US
Practice Address - Phone:954-483-9664
Practice Address - Fax:954-281-5881
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID79197363LP0808X
FLAPRN11000307363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health