Provider Demographics
NPI:1043456007
Name:KETCHUM, MARK (RN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KETCHUM
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3061 E 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHGLENN
Mailing Address - State:CO
Mailing Address - Zip Code:80233-5475
Mailing Address - Country:US
Mailing Address - Phone:720-271-0628
Mailing Address - Fax:303-953-1217
Practice Address - Street 1:3061 E 109TH AVE
Practice Address - Street 2:
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80233-5475
Practice Address - Country:US
Practice Address - Phone:720-271-0628
Practice Address - Fax:303-953-1217
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-22
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO176755163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health