# KETTLY HOUSE LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1457231003
- **Authorized official:** KETTLY DERIVAL RN (CEO)
- **Authorized official phone:** (954) 546-0667

## Contact information

- **Practice address:** 2191 NW 74TH AVE, SUNRISE, FL 33313-3855
- **Practice address phone:** (954) 546-0667
- **Mailing address:** 2191 NW 74TH AVE, SUNRISE, FL 33313-3855
- **Mailing address phone:** (954) 546-0667

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 163WC1500X | Community Health Registered Nurse | — | NULL | Yes |
| 163WC1500X | Community Health Registered Nurse | — | — | Yes |
| 320900000X | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility | — | NULL | — |

## Other

- **Enumeration date:** 09/04/2025
- **Last updated:** 09/04/2025