Provider Demographics
NPI:1629094404
Name:KETLER, PATRICIA (RN, MSN, APRN, BC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:KETLER
Suffix:
Gender:F
Credentials:RN, MSN, APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 RECKORD RD
Mailing Address - Street 2:
Mailing Address - City:FALLSTON
Mailing Address - State:MD
Mailing Address - Zip Code:21047-2443
Mailing Address - Country:US
Mailing Address - Phone:410-879-3431
Mailing Address - Fax:
Practice Address - Street 1:104 PLUMTREE RD
Practice Address - Street 2:SUITE 115
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-6095
Practice Address - Country:US
Practice Address - Phone:410-515-4300
Practice Address - Fax:410-515-4318
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR053356363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD521304500Medicaid
039889OtherJOHNS HOPKINS HEALTHCARE
250391OtherKAISER
MD93119Medicaid
0016OtherCAREFIRST DC
110835OtherCOVENTRY
691571OtherNCPPO
61318201OtherCAREFIRST MARYLAND
61318201OtherCAREFIRST MARYLAND
110835OtherCOVENTRY