Healthcare Provider Details

I. General information

NPI: 1033428198
Provider Name (Legal Business Name): KATHLEEN KETELSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2010
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 E BELL RD STE 205
SCOTTSDALE AZ
85254-6002
US

IV. Provider business mailing address

PO BOX 1200
PLEASANT GROVE UT
84062-1200
US

V. Phone/Fax

Practice location:
  • Phone: 800-640-3451
  • Fax:
Mailing address:
  • Phone: 800-640-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number287380
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201050158NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: