Basic Information
| Provider Information | |||||||||
| NPI: | 1710103494 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KETOLA | ||||||||
| FirstName: | NANCILYN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | W194S8371 SUMMERIDGE CT | ||||||||
| Address2: | |||||||||
| City: | MUSKEGO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531508165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146871122 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2315 E MOORELAND ROAD | ||||||||
| Address2: | |||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627987200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 09/26/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2184-154 | WI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 1710103494 | 05 | WI | MEDICAID |