Provider Demographics
NPI:1710068010
Name:KETZEL, GAYLE J (ARNP)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:J
Last Name:KETZEL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 3RD AVE N STE 101
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-3208
Mailing Address - Country:US
Mailing Address - Phone:206-523-0589
Mailing Address - Fax:425-967-3260
Practice Address - Street 1:131 3RD AVE N STE 101
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3208
Practice Address - Country:US
Practice Address - Phone:206-523-0589
Practice Address - Fax:425-967-3260
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003557363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health