Basic Information
| Provider Information | |||||||||
| NPI: | 1427064948 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | KETTERHAGEN | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | N17W24100 RIVERWOOD DR | ||||||||
| Address2: | PROHEALTH CARE MEDICAL ASSOCIATES, INC. | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531881177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629284100 | ||||||||
| FaxNumber: | 2629285835 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 AMERICAN AVE | ||||||||
| Address2: | PROHEALTH CARE MEDICAL ASSOCIATES, INC. | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531885031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629283500 | ||||||||
| FaxNumber: | 2625440382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 11/09/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2160-033 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 36011100 | 05 | WI | MEDICAID |