Healthcare Provider Details

I. General information

NPI: 1073040515
Provider Name (Legal Business Name): CANDICE KETELSEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CANDICE KLEMENS PA

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 S ROYLE RD
RIDGEFIELD WA
98642-7759
US

IV. Provider business mailing address

536 S ROYLE RD
RIDGEFIELD WA
98642-7759
US

V. Phone/Fax

Practice location:
  • Phone: 360-487-1086
  • Fax: 360-487-1088
Mailing address:
  • Phone: 360-487-1086
  • Fax: 360-487-1088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60758102
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1496
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: