Provider Demographics
NPI:1982719837
Name:KETZLE, TIFFANY MERRILL (APRN ANP-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MERRILL
Last Name:KETZLE
Suffix:
Gender:F
Credentials:APRN ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-7738
Mailing Address - Country:US
Mailing Address - Phone:972-867-0129
Mailing Address - Fax:
Practice Address - Street 1:6513 PRESTON RD
Practice Address - Street 2:SUITE 300
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-2688
Practice Address - Country:US
Practice Address - Phone:972-608-2025
Practice Address - Fax:972-608-2032
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX681853363LA2200X
TXAP111326363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L6427Medicare PIN
TX8L11357Medicare PIN