Provider Demographics
NPI:1073040515
Name:KETELSEN, CANDICE (PA)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:KETELSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:
Other - Last Name:KLEMENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:
Practice Address - Street 1:2500 W A ST STE 101
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-6000
Practice Address - Country:US
Practice Address - Phone:208-882-0540
Practice Address - Fax:208-883-1853
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60758102363A00000X
363A00000X
IDPA-1496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant