Provider Demographics
NPI:1619347531
Name:KETELSEN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KETELSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10330 MERIDIAN AVE N STE 300
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-9463
Mailing Address - Country:US
Mailing Address - Phone:206-368-6100
Mailing Address - Fax:
Practice Address - Street 1:10330 MERIDIAN AVE N STE 300
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-9463
Practice Address - Country:US
Practice Address - Phone:206-368-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60434105163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse