Provider Demographics
NPI:1922495746
Name:KETTELL-SLIFER, LYNN (ARNP)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:
Last Name:KETTELL-SLIFER
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 1:479 HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-2411
Mailing Address - Country:US
Mailing Address - Phone:904-531-9504
Mailing Address - Fax:
Practice Address - Street 1:479 HOUSTON ST
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-2411
Practice Address - Country:US
Practice Address - Phone:904-531-9504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9341571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily