Provider Demographics
NPI:1396895942
Name:KETTERLING, MARCIA (FNP C)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:KETTERLING
Suffix:
Gender:F
Credentials:FNP C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:701-584-3011
Practice Address - Street 1:302 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:ND
Practice Address - Zip Code:58533
Practice Address - Country:US
Practice Address - Phone:701-584-3010
Practice Address - Fax:701-584-3011
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR17917363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19632Medicaid
ND23182OtherBLUE CROSS BLUE SHIELD
ND23182OtherBLUE CROSS BLUE SHIELD
ND19632Medicaid