Provider Demographics
NPI:1679374417
Name:KETTER, PHEONA (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:PHEONA
Middle Name:
Last Name:KETTER
Suffix:
Gender:
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3108 S HEMLOCK CT
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7602
Mailing Address - Country:US
Mailing Address - Phone:918-951-0213
Mailing Address - Fax:
Practice Address - Street 1:4785 E 91ST ST STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-2839
Practice Address - Country:US
Practice Address - Phone:918-313-4458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator