Provider Demographics
NPI:1174280903
Name:KETCHAM, HALEY ANN (FNP)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:ANN
Last Name:KETCHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LONG LN
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-2641
Mailing Address - Country:US
Mailing Address - Phone:631-566-5217
Mailing Address - Fax:
Practice Address - Street 1:6 LONG LN
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-2641
Practice Address - Country:US
Practice Address - Phone:631-566-5217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF348701363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily