Provider Demographics
NPI:1669129383
Name:KETTLE, KODY S
Entity type:Individual
Prefix:
First Name:KODY
Middle Name:S
Last Name:KETTLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24805 PINEBROOK RD STE 314
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-4128
Mailing Address - Country:US
Mailing Address - Phone:703-957-3373
Mailing Address - Fax:
Practice Address - Street 1:24805 PINEBROOK RD STE 314
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20152-4128
Practice Address - Country:US
Practice Address - Phone:702-957-3373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01045557796111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor