Provider Demographics
NPI:1235609850
Name:KETCHEM, KRYSTAL MELINDA
Entity Type:Individual
Prefix:MS
First Name:KRYSTAL
Middle Name:MELINDA
Last Name:KETCHEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:786 MCCOOL RD SUITE 8
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385
Mailing Address - Country:US
Mailing Address - Phone:219-617-1142
Mailing Address - Fax:
Practice Address - Street 1:786 MCCOOL RD SUITE 8
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385
Practice Address - Country:US
Practice Address - Phone:219-617-1142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist