Provider Demographics
NPI:1629390810
Name:KETCHUM, MARILYN CARMELA (RN, CANP)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:CARMELA
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:RN, CANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-4018
Mailing Address - Country:US
Mailing Address - Phone:517-346-7628
Mailing Address - Fax:517-346-7629
Practice Address - Street 1:2310 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4018
Practice Address - Country:US
Practice Address - Phone:517-346-7628
Practice Address - Fax:517-346-7629
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704149979163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice