| NPI | 1164806956 |
|---|---|
| Former Name | STACEY JO KETTLEWELL |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: WV 1904) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical |
| Enumeration Date | 2015-07-12 |
| Last Update Date | 2019-10-18 |