Healthcare Provider Details

I. General information

NPI: 1477892321
Provider Name (Legal Business Name): SHERRY LYNN KETNER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2013
Last Update Date: 01/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 SAWYER DR STE 100
DURANGO CO
81303-3409
US

IV. Provider business mailing address

185 SUTTLE ST ATTN: AXIS HEALTH SYSTEM- CREDENTIALING
DURANGO CO
81303-8276
US

V. Phone/Fax

Practice location:
  • Phone: 970-335-2220
  • Fax: 970-247-5255
Mailing address:
  • Phone: 970-335-2232
  • Fax: 970-565-9005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.0091113
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN0990586
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License NumberAPN0990586
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP0990586
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: