MEDICARE: LISA KETELSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN60434105	WA

General Provider Information

NPI Number	:	1619347531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA KETELSEN

Provider Business Mailing Address
First Line	:	10330 MERIDIAN AVE N STE 300
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98133-9463
Country	:	US
Telephone Number	:	206-368-6100
Fax Number	:

Provider Business Practice Location Address
First Line	:	10330 MERIDIAN AVE N STE 300
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98133-9463
Country	:	US
Telephone Number	:	206-368-6100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2015
Last Update Date	:	10/05/2015

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