Provider Demographics
NPI:1750596839
Name:KETTELL, MERRILEE R (FNP)
Entity type:Individual
Prefix:MS
First Name:MERRILEE
Middle Name:R
Last Name:KETTELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:MERRILEE
Other - Middle Name:R
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5125 SKYWAY
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-5624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5125 SKYWAY
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-5624
Practice Address - Country:US
Practice Address - Phone:530-872-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP10874363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS86496Medicare UPIN